This blog is part of a series to highlight the dangers of the repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

Lesbian, Gay, Bisexual and Transgender (LGBT) older adults face many of the same health and aging challenges other older adults face, but more pronounced. As a result, they are arguably more at risk if the incoming administration and Congress repeals the Affordable Care Act (ACA) without a replacement plan and/or makes significant and harmful changes to Medicaid and Medicare.

LGBT older adults face unique risks within the health care system due to the standard issues facing an aging population combined with their sexual orientation or gender identity, such as:

  • Aging Combined with Discrimination: Similar to the older population in general, LGBT older adults face challenges with aging: declining health, diminished income, and the loss of friends and family. LGBT older adults, however, also face the added burden of actual or feared discrimination on the basis of their sexual orientation and/or gender identity. Many choose to go back into the closet for fear that caregivers will discriminate against them. Transgender adults, however, do not even have that option. Despite federal prohibitions on discrimination based on sex stereotyping and gender identity and the prohibition of discriminatory practices toward LGBT individuals based on health status - such as being HIV positive - built into the ACA, the sex stereotyping and gender identity protections are currently under attack in the courts, and LGBT older adults remain one of the most invisible, underserved and at-risk elder populations.
  • Isolation from Society, Services and Supports: Studies show that LGBT older adults are twice as likely to live alone; half as likely to have close relatives to call for help; and more than four times less likely to have children to help them. Nearly one-in-four LGBT older adults has no one to call in case of an emergency. At the same time, studies document that LGBT older adults access essential services – including visiting nurses, food stamps, senior centers and meal programs – much less frequently than the general aging population.
  • Lack of Access to Culturally Competent Health Care: The U.S. Department of Health and Human Services has found that LGBT older adults face additional health barriers because of isolation combined with a lack of access to social services and culturally competent providers. These barriers result in increased rates of depression; higher rates of alcohol and tobacco use; and lower rates of preventive screenings. 
  • Higher Rates of Poverty: LGBT older adults reflect the diversity of our nation in terms of gender, race and ethnic identity. But there is one critical statistic where they do not reflect the norm: they have much higher poverty rates and lower average household income than their straight and cis-gender counterparts. In fact, 35 percent of SAGE clients in New York City have annual pre-tax incomes below $10,000 and rely on Medicaid – a program with looming threats of block grants or per capita caps - to provide their medical care. An additional 35 percent subsist on annual pre-tax incomes of $20,000 or less and qualify for coverage under Medicaid expansion or could utilize tax credits to purchase insurance on the Marketplace. The Medicare-eligible segment of this population benefits from the ACA having lowered Medicare Part B premiums, the closing of the “donut hole” for prescription drugs, and payment and delivery reforms aimed at improving quality and the coordination of care for individuals with complex care needs.
  • HIV: As of 2015, the CDC estimates that one in two people who are HIV positive in the United States are now over 50. Yet little attention and money is targeted towards prevention for this population. One of the free preventive services covered by the ACA is HIV screening, though recommended testing in the U.S. cuts off at age 64. As a result, older adults are much more likely to be dually diagnosed with HIV and AIDS if and when they are ultimately tested.

Because of higher rates of health disparities, un-insurance, poverty and a greater reliance on programs like Medicaid and Medicare - two programs that could be facing significant retooling and subsequent funding cuts in the coming years - the protections provided by these programs and enacted in the ACA are critical for improving the quality of life for older LGBT individuals.

As we enter an uncertain time, we believe that we must do more to honor and support the LGBT elders who fought the fight and paved the way for the recent advances we have seen on LGBT rights. The least we can do is ensure that this population still has access to the foundational supports provided by the ACA, Medicaid and Medicare.

Aaron Tax, Director of Federal Government Relations, Services and Advocacy for GLBT Elders (SAGE)

With their agenda so at odds with the preferences of even their own voters, it is no wonder congressional Republicans are focusing their attention on the alleged shortcomings of the Affordable Care Act (ACA) rather than on what they actually propose to do. In order to escape responsibility for the damage they will do to the health system by repealing the ACA, they will try to paint a misleading picture of the law. First, they will entirely omit any discussion of the law’s accomplishments; second, they will advance a series of misleading arguments. That strategy was on full display with House Energy and Commerce Chair Greg Walden’s recent release of an "Obamacare Reality Check.” While repeating opposition arguments isn't generally good messaging practice, there are a few other significant problems with the "reality check":

  • Yes, enrollment is lower than originally projected, but that’s partly because fewer employers have dropped coverage than Congressional Budget Office expected. A lot of people would say that is a good thing. And while cost-per-beneficiary is higher than projected, total cost is much lower.
  • Many analysts believe that the premium increases of the past year represent a one-time correction (or would, were it not for the dramatic uncertainty the repeal effort is creating in insurance markets).
  • Also conveniently ignored is the fact that congressional Republicans have actively, and in part successfully, worked to cause premiums to rise by restricting reinsurance payments.

Access to plans has declined in the past year, but repeal will make the problem much worse by causing the non-group insurance market to essentially unravel. Also unmentioned, before the ACA, millions were locked out of coverage entirely because of pre-existing conditions. The lack of plan choice mainly shows up in rural areas that didn't have a lot of plan choices before the ACA was passed.
Finally, the total cynicism of the Republican attack on the ACA is revealed in their discussion of high cost sharing. Not only do they blame increases in employer plan deductibles on the ACA
(something the law had nothing to do with), but all of their proposed replacement plans rely heavily on high-deductible plans and generally promote skimpy coverage that would make the problem much worse. As former president Bill Clinton said, it takes some brass to attack someone for doing what you yourself are doing.

Looking Before They Leap?

Although so far there is no indication that Republican leaders are rethinking their approach to the ACA, not everyone in the party seems so eager to drive the health care system off a cliff with nothing more than a hope that something will turn up to prevent the fiery crash before it is too late. An increasing number of Republican senators are voicing concerns about the ‘repeal now replace later’ strategy. And some are waking up to the fact that repealing in haste now could make replacing later much more difficult. Of course, voicing concerns is not the same as actually voting against repeal with no replace. Nor should anyone imagine that any of these senators has learned to stop worrying and love the ACA. But just the fact that they are starting to think seriously about the implications of what their leadership is rushing them to do is an important step in the right direction.

This blog is part of a series to highlight the dangers of repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

Following the election of Donald Trump, immigrant communities have grown increasingly anxious about their safety and well-being. The president-elect’s hard-lined stance on anti-immigrant policies has stoked fear among undocumented immigrants and further heightened concerns about discrimination, families being separated, job security and access to health care for millions of people.

The ACA has significantly increased access to affordable health coverage for lawfully present immigrants through Medicaid expansion and health insurance Marketplaces with tax credit subsidies. For example, from 2013 to 2014, the percent of noncitizens with health care coverage jumped by 6.3 percent.

Percent Insured by Citizenship

Image Attribution: Screenshot taken from on 1/11/2017

The Affordable Care Act was built upon the success of extending (or lifting) five-year coverage to children and pregnant women through CHIPRA. In 2009, Congress Reauthorized the Children’s Health Insurance Program (CHIP), including the Legal Immigrant Children’s Health Improvement Act (ICHIA) provision allowing states the option to lift the five-year waiting period for lawfully present immigrants to enroll in Medicaid coverage. States such as Ohio, Utah and Florida recently adopted ICHIA to extend health coverage to immigrant children and pregnant women. This coverage option was critically important in ensuring that low-income immigrant women have healthy pregnancies and healthy babies. While recipients of the Deferred Action for Childhood Arrival’s (DACA) program were excluded from the Affordable Care Act’s coverage options, some states took an additional step to extend health coverage to undocumented immigrants. California, for example, deemed DACA recipients eligible for Medicaid coverage under Permanently Residing in the United States Under Color of Law (PRUCOL). The president-elect’s stance on programs benefitting immigrant communities sends a troubling signal about potential cuts and changes impacting immigrant families.

The upcoming debate around refunding CHIP should ensure that advocates maintain current eligibility criteria so that immigrant families and children continue to access the care they need. The push for Medicaid block grants and per capita caps threatens to lessen federal dollars going into states to support immigrant health programs. The movement to end programs benefitting DACA recipients and other groups under PRUCOL is yet another challenge. It’s no surprise that immigration lawyers, for example, have reported seeing a ten-fold increase in calls from immigrant clients concerned about what Donald Trump’s election means for their families. 

Consumer health, immigrant and social justice advocates can play an active role in protecting immigrants at risk of losing available health coverage options. Identify whether your state has taken up the ICHIA option. Continue educating and informing immigrant communities about available health care options and protections at local enrollment and community events. Determine how your organization can complement ongoing initiatives to educate and inform immigrants about their rights and protections. Highlight the ACA’s role in improving health care access within immigrant communities. Identify, collect and elevate the stories of immigrants whose lives have been improved by the ACA. Explore ways to partner with local groups reaching immigrant populations to support immigrant families, foster productive partnerships and further elevate the importance of the ACA for diverse constituencies across the country. All of this will go a long way for advocates to serve as a strong, vocal ally for protecting immigrant communities and their health coverage.

Paul Ryan - To-do list

Many people, including many conservatives, have argued that repealing the Affordable Care Act without a replacement plan is a problem. But it is not only the content of "replace" that remains mysterious, it’s also the details of "repeal." Maybe Republicans are reluctant to specify what repeal would entail because the implications of the repeal bill they passed in 2015 are so disastrous. The more people understand the effects of repeal, the less they will like it. (That's also the reason for the extreme haste. The longer the issue hangs out there, the clearer are the negative consequences of a hasty move to repeal.)

So let's cut through the fog and look at what the real repeal agenda and its effects would be.
  1. Cut taxes for rich people. This staple of Republican policy making is never out of style. Tax cuts were a central part of the reconciliation bill that was passed by Republicans in 2015 and vetoed by President Obama. If this element of repeal is retained, it will essentially make it impossible to come up with a viable replacement plan because there will be no revenue to pay for subsidies.
  2. Take health insurance away from 30 million people. With no viable replacement plan, the non-group insurance market is likely to implode. That, along with the elimination of the Medicaid expansion adopted by 31 states (32 states if North Carolina's proposed expansion goes through), will cause a precipitous decline in coverage and more than undo the progress made by the ACA.
  3. Increase hospital uncompensated care by one trillion dollars. Once the money and coverage are gone, other dominoes start to fall. The expansion of coverage to millions of low- and moderate-income people has reduced the burden of uncompensated care on hospitals, helping their bottom line and better enabling them to invest in quality improvements like reducing readmissions and hospital-acquired infections. It has also stabilized the finances of many rural and safety-net hospitals.
  4. Reduce employment. But wait, there's more. Researchers at George Washington University estimate that ACA repeal (with no replacement) would cause the loss of approximately 2.6 million jobs, almost all in the private sector. Many would be health care jobs, but many other sectors would be impacted, as well.
  5. Increase state costs while lowering state revenues. Expanding Medicaid has allowed many states to draw down federal matching funds for services that were previously paid for with 100 percent state dollars. Repeal of the ACA's Medicaid expansion would eliminate those matching funds and shift those costs back onto states. As state costs increase, revenues would decline as a result of fewer people working and paying taxes.
  6. Increase the federal budget deficit. It's not just state budgets that would suffer. A recent analysis by the Committee for a Responsible Federal Budget found that ACA repeal would increase the budget deficit by $350 billion over ten years, even before any money was spent on a replacement plan.
  7. Deny women access to reproductive health services. And, as if all of this was not enough, Speaker Ryan recently added insult to injury by confirming that the reconciliation bill would not stop at dismantling the ACA but would also include a block on federal funding for Planned Parenthood. None of that federal funding goes for abortions – it goes toward other important services such as cancer screenings that would likely be curtailed. Some clinics could also be forced to close.

Blame It On Someone Else

Last but not least, perhaps the most important part of the agenda is not what repeal does, but what repeal proponents can get the American people to believe. Congressional Republicans will try to convince people that all of the harmful consequences of the reckless repeal-with-no-replace strategy would have happened anyway. That is why they are spending a lot of time talking about what is wrong with the ACA instead of what provisions of the law they are actually going to repeal. And who can blame them – tax cuts for the rich and benefit cuts for working families, job losses, hospital closures, and state budget crises are not a very attractive policy menu. And it's also not at all what voters, including Republican voters, want.

So, What Do Voters Really Want?

We know that strong majorities, including a majority of Republicans, support both tax credits to make coverage affordable and the Medicaid expansion. Most people probably don't know that these provisions have been targeted for repeal, but if they did, they would likely not be supportive. We also know that only about 20 percent of the population actually favors the current "repeal now replace later (maybe)" approach that Republicans are currently pursuing. Finally, both polling and focus groups have recently found that Trump voters’ health care priorities are to reduce out-of-pocket costs and keep drug prices down. 

Part II: Reality Checking the Reality Check

Read tomorrow’s part two of The Takeaway on the problems with congressional Republicans’ “reality check” on the ACA.

This blog is part of a series to highlight the dangers of repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

Olivia's Story

In 2014, Community Catalyst shared Olivia Richard’s story in a video. Olivia is enrolled in the One Care program, the Massachusetts demonstration project which coordinates care for people with disabilities eligible for both Medicare and Medicaid (“dual eligibles”). Olivia uses a wheelchair and relies on personal care attendants (PCAs) to help her with activities of daily living. Before enrolling in the One Care program, she had not been receiving an adequate amount of PCA hours, nor other services she needed to achieve the quality of life and degree of independence she envisioned for herself. After enrolling in One Care, Olivia was able to live independently, with services that met her needs, preferences and goals, thanks to a coordinated plan developed together with her Independent Living-Long Term Services and Supports Coordinator. This was possible because of the Affordable Care Act (ACA), which enabled the creation of the dual eligible demonstration projects now ongoing in Massachusetts and 12 other states (formally termed the Financial Alignment Initiative.)

Fast forward to November 9, 2016: Individuals like Olivia now face the serious possibility that this much-improved coordination of their Medicare and Medicaid benefits may be significantly undermined by repeal of the ACA, impacting the delivery of critical services. Dual eligibles are a particularly vulnerable population – doubly in the line of fire – not only from the immediate attack on the ACA, but also from proposals circulating among the Republican-controlled Congress that threaten to seriously undermine each program in other ways in the future.

Beyond the unfolding rush to repeal the ACA, proposals in favor among Republican congressional leaders and the nominee for HHS Secretary, Rep. Tom Price, would permanently rework the structure and financing of Medicaid and could end the existing guarantee of coverage for all those who qualify for the program. In addition, House Speaker Paul Ryan has for years floated proposals to change Medicare from a defined benefit program to one in which adults over 65 get “premium support” to purchase private insurance, a plan slanted toward benefitting those older adults who are more affluent and in better health, leaving low-income elders in poorer health without the safety net that they have counted upon.

Who Are the Duals?

Dual eligible beneficiaries are entitled to Medicare either by virtue of age (being 65 or older) or by having a permanent disability and receiving Social Security Disability Insurance (SSDI). They are also eligible for Medicaid based on low-income eligibility guidelines. Currently, there are over 10 million dually eligible beneficiaries, with the majority (59 percent) aged 65 and older, and with most of them (73 percent) also eligible for full Medicaid benefits. Dually eligible beneficiaries comprise 14 percent of all Medicaid beneficiaries, but account for 33 percent of Medicaid spending; they also make up 20 percent of the Medicare population, but account for 35 percent of Medicare spending. In part, this disproportionate spending is because dual eligibles tend to have complex health needs, with higher rates of diabetes, mental illness and cognitive impairment. Another reason is that these beneficiaries have to navigate two complex systems, Medicare and Medicaid, which more often than not, has resulted in very fragmented and inefficient care. 

Altering Medicaid Will Have Serious Implications

The most significant implication of GOP proposals to restructure Medicaid – like changing to block grant or per capita cap funding methods – is the strong likelihood that eligibility will be limited and critical services will be cut, as the total federal dollar payments to states would be greatly reduced. Block grants or per capita caps would also limit states’ abilities to pursue innovative strategies that address issues beyond medical services such as access to long-term services and supports and the addressing of social determinants of health, which result in better integrated and more coordinated care. This is true for many low-income populations, but the dually eligible population is particularly at risk.

Medicaid, especially since the passage of the ACA, has served as fertile ground for innovative solutions to addressing health care cost, quality and access issues. Medicaid programs have been vital to improving care for dual eligibles, often serving as a catalyst for innovation. Fundamental changes to the Medicaid program could jeopardize such innovative programs as:

  • The Dual Eligible Demonstration Projects: as noted above, thirteen states are running demonstration programs – like the One Care program in Massachusetts helping Olivia – to better align the financing of the Medicare and Medicaid programs in order to better integrate services for dual eligible enrollees. These demonstration projects could not have been possible without the ACA creating the Center for Medicare and Medicaid Innovation (CMM) and the Medicare-Medicaid Coordination Office (MMCO) within CMS.
  • Medicaid Accountable Care Organizations (ACOs): ten states are actively running Medicaid ACO programs to improve care coordination and delivery of Medicaid benefits by holding providers accountable through quality improvements, increased financial risk and innovative information technology. Some states are using or are planning to use ACOs as a model of care for dual eligibles, such as Maryland and Oregon.
  • Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents - the MMCO and CMMI are spearheading an initiative to help improve the quality of care for people in long-term care (LTC) facilities by reducing potentially avoidable inpatient hospitalizations. The most recent evaluation report for this initiative shows a decline in all-cause hospitalizations and potentially avoidable hospitalizations in participating sites. The evaluation report also finds that there were reductions in overall Medicare expenditures relative to a comparison group.

Innovations such as these will be seriously impacted if the ACA is repealed and/or if Medicaid funding were to be radically undermined. Investments in delivery and payment reform in Medicaid are critical and must continue. The dual eligible population has complex medical and social needs and taking away needed services and shifting costs onto a group of consumers the least able to take on new financial stresses is bad policy. If innovative changes to our health care system can work better for the most vulnerable, they can work better for everyone. Stakeholders, including providers, plans, payors and advocates, need to come together now and raise their voices loudly to protect the ACA and the Medicaid program itself. This fight is nothing less than a fight for health care justice, period.