Posts About Health Equity

Despite his repeated promises on the campaign trail that he would not cut Medicaid, President Trump’s FY 2018 budget would slash the program’s budget nearly in half over the next decade. The budget assumes the $839 billion in Medicaid cuts in the American Health Care Act (AHCA) become law, and then calls for an additional $627 billion in cuts to the program, all while slashing other safety net programs too.

An attack on health and economic security for low-income communities

Cuts of this magnitude would put at risk the health of the millions of older adults, people with disabilities, children and low-income families who depend on Medicaid for their care. They would undermine a program that is essential to the fight against the opioid epidemic. And they would rock the economic security of low-income communities, who depend on Medicaid coverage to protect them against crippling medical debt.

What’s more, the Trump budget pairs these Medicaid cuts with deep cuts to other essential health and social welfare programs - like food stamps and disability insurance. Together, these programs not only boost economic security for low-income families, they also contribute to health security by putting healthy foods and safe housing within reach of families who could not otherwise afford them. By slashing these programs alongside Medicaid, the Trump budget is an all-out attack on the health and economic security of vulnerable communities.

A wakeup call for America’s governors

While many governors have expressed concern about how the AHCA ends the enhanced funding for the ACA’s Medicaid expansion, they have said relatively little about how it also turns Medicaid into a per capita cap. This budget should be a wake-up call for those governors: per capita caps are a Trojan horse that will allow the federal government to balance its budget at the expense of state budgets.  

While budget documents don’t make it entirely clear how the administration would achieve over $600 billion additional savings in Medicaid, Trump’s budget director Mick Mulvaney explained that the additional funding cuts result from a reduction to the growth rate for the per-capita cap, compared to the AHCA. That’s just a backdoor way of shifting Medicaid costs from the federal government on to states.

The Trump budget exposes as wishful thinking any assumptions that governors may have made that they could weather the AHCA’s cuts to Medicaid by utilizing additional “flexibility”. The AHCA doesn’t merely make $839 billion in Medicaid cuts; it creates a dial that Congress and the administration can and will ratchet down any time they want additional savings. The $1.47 trillion in Medicaid cuts inherent in Trump’s budget this year is likely just the beginning.

Additional cuts targeted at children

Trump’s budget also targets the Children’s Health Insurance Program (CHIP), which provides health insurance to children of low- and moderate-income families who are not eligible for Medicaid. In 2016, CHIP covered nearly 8.9 million kids, while Medicaid covered about 37 million. Together with Medicaid, CHIP coverage has helped lower the uninsurance rate for children to a historic low of 4.8 percent.

CHIP is currently funded through September 30, 2017 but will need another funding extension in order to continue past that date. The Trump administration’s proposed budget would extend CHIP funding for only two years despite the recommendation from the Medicaid and CHIP Payment and Access Commission to extend funding for five years.

The proposed budget would end the higher federal CHIP matching rate known as the 23 percent bump and eliminate the Affordable Care Act’s Maintenance of Effort requirement at the end of September—two years earlier than the ACA intended. It also assumes the AHCA provision that rolls back eligibility for school-aged children from 138 percent FPL to 100 percent FPL—potentially affecting millions of children. We know that Medicaid and CHIP disproportionately cover children of color, so not only is this a loss in coverage but a step backward in our efforts to address health equity.

Trump’s budget would further undermine CHIP’s efficacy by eliminating federal enhanced matching funds to children above 250 percent of the Federal Poverty Level. This is particularly problematic because in many states CHIP eligibility extends beyond this marker. For example, Alabama provides CHIP coverage up to 317% FPL and New York goes up to 405% FPL. By capping these CHIP eligibility levels, the Trump budget reduces state flexibility in meeting the needs of children. Overall, the Trump administration’s budget does not help advance children’s health, instead it puts us in danger of reversing our hard won coverage gains.

“Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.”
- Dr. Martin Luther King, Jr.

This is the first in a blog series highlighting the impact of structural racism in our health system.

Despite national and local efforts to address disparities, people of color continue to experience poorer health than their white counterparts, including higher rates of infant mortality, lower life expectancy and increased prevalence of chronic diseases. Health disparities among racial and ethnic groups are persistent and drive up the cost of care for everyone. The root causes of these disparities are the result of systemic racism within our health system and society. These causes are complex and interrelated and include social and economic determinants (such as income level, education, and living conditions in homes and neighborhoods). In recognition of National Minority Health Month, we felt it was important to unpack the systemic racism embedded in the final rule on market stability the Trump administration recently released.

Although we still have far to go in eliminating health disparities, the Affordable Care Act is a step in the right direction on health equity.

Thanks to the Affordable Care Act, people of color, especially Blacks and Latinos, have had major coverage gains over the past few years. Approximately 12.2 million people—32 percent of those are people of color—are currently enrolled in the marketplace. The uninsured rate for Latinos dropped from 36 percent pre-ACA to 29 percent in the first quarter of 2016. Similarly, the uninsured rates for Blacks dropped from 21 percent in 2013 to 13 percent in 2016. Expanding health insurance coverage is certainly a necessary condition for advancing health equity. However, it is not a sufficient one on its own. People of color face many barriers when accessing quality health care. According to the 2015 National Healthcare Disparities report, compared to their white counterparts, people of color experience significant disparities in both access to care and in the quality of care they received. Summarizing a range of access and quality measures, the report found that Blacks and Latinos had worse access to care on 14 of the 20 access measures than Whites. Blacks, Latinos and American Indians and Alaska Natives received worse care than Whites for about 40 percent of quality measures.

In contrast, in its first health care regulatory action, the Trump administration puts in place policies that disproportionately affect communities of color.

In an attempt to reduce the above disparities, the Affordable Care Act requires Marketplace health plans to include within health insurance plan networks at least 30 percent of essential community providers (ECPs), such as community health centers, family planning clinics, safety-net hospitals, Ryan-White AIDS providers and Indian Health Services Centers, that serve predominately low-income, medically-underserved individuals. These providers have been the primary source of care for populations with the greatest health needs. For women, particularly low-income women and women of color, clinic-based providers, family planning clinics and health centers, are important sources of reproductive and sexual health care. Many ECPs are also on the forefront of providing culturally and linguistically competent services and have worked hard to win the trust of their diverse patient base.

ACA statute and resulting regulations, while not as robust as we would like, are aimed at more equitable access to care for individuals and families who live in low-income and underserved communities, who are disproportionately people of color. Unfortunately, in the final rule on market stability, the Trump administration weakened ECP inclusion standards. For 2018, health plans will only need to include 20 percent (or even less) of ECPs within their network rather than 30 percent. A rollback on standards of essential community provider (ECP) disproportionately affect communities of color. This rule change will restrict access to health services, increase travel times to care facilities and reduce access to culturally and linguistically appropriate health care providers. At its core, the final rule reinforces systemic racism by perpetuating structural barriers to better health for people of color.

As we defend the ACA on all fronts, we must be vigilant in responding to and highlighting changes to rules and regulations that perpetuate structural racism.

The change in the ECP standards is just one example of harmful regulatory changes that rollback our efforts to promote health equity. Community Catalyst, alongside national, state and local partners, is working to protect the ACA from repeal but even during that fight, we must work together to amplify when and how ACA health equity provisions are reversed and/or diminished.

Thanks to thoughtful contributions from various teams at Community Catalyst, including the Private Insurance Team, The Children’s Health Team, The Substance Use Disorders Team and the Health Equity Executive Team.

There are already reams of postmortems about last week’s collapse of the drive to repeal the Affordable Care Act. It will probably become a case study for students of policy and politics (file under "what not to do"). Nevertheless, with the benefit of a few days of reflection, we can reach some good conclusions about what went down and draw some lessons for the future.

Why Did the AHCA Fail?

There is no shortage of figures to credit (or blame, depending on your point of view) for the demise of the American Health Care Act (AHCA): Democrats (in general and former Obama officials, in particular); the Freedom Caucus in the House; House Speaker Paul Ryan; the organizers at MoveOn and Indivisible; the Trump administration's own incompetence; and even the GEICO lizard. So, what really killed the AHCA?

There is some truth in the answer "all of the above" (well, maybe not the lizard). Part of the reason is indeed the division within the Republican Party and the extremism and intransigence of many of its members. The reason GOP party leaders did not have a workable replacement plan ready to go by now should be obvious, and it is not solely because there was no point in doing the heavy policy and political lifting while Obama was president. Republican political leaders didn’t have a replacement plan ready because a large segment of the party is unwilling to confront the fact that the pillars of the ACA – competitive private insurance markets, tax credits for affordability and some kind of hedge against free-riding/ adverse selection--are essentially Republican health policy.

Even the minimal inclusion of these elements in AHCA, sweetened with big tax cuts for the rich and a big Medicaid cut, were too much for the Freedom Caucus. This is the same group of extremists that shut down the government back in 2013 and drove John Boehner (who must be laughing his head off) from the speakership.

In an effort to appease this faction, the “finished product” that almost reached the House floor didn’t stop with cutting the tax credits and Medicaid coverage the ACA provided. It undermined care for millions of children, seniors and people with disabilities, included a whopping premium increase for older adults and created a new opportunity for insurers to deny coverage to people with many serious and chronic conditions. “Trumpcare” (or “Ryancare,” if you prefer) was also a major economic blow to providers of care and state budgets. In short, it was not just an attack on the health and economic security of millions of people, it was a full-frontal assault on an economic sector that accounts for millions of jobs and about one-sixth of all the economic activity in the country.

But blaming the Freedom Caucus lets too many others off the hook. Let’s not forget that Speaker Ryan was actually the chief architect of the bill, which the Trump administration enthusiastically embraced.

This Is What Democracy Looks Like

Intra-party infighting has gotten a lot of press coverage, but it is only part of the story, and not the most important part. The rapid mobilization of opposition was critical. It forced Republican leaders to abandon their "repeal and delay" strategy and put an alternative to the ACA on the table. Once people got a good look at “replace” – 24 million losing coverage, $880 billion in reduced federal support to states, job losses, higher out-of-pocket costs – and heard the compelling stories of people whose health and lives would be in jeopardy, thousands took to the streets and flooded the Congressional switchboard in protest.

Nor was this just a victory of the "left" or a small set of organizations or individuals. It was a victory for an ideologically heterogeneous public engaging in civic action to stop a narrow faction of extremists bent on undermining their health care. You cannot mobilize people around something about which they do not care. Fortunately, people care about health care. Above all, as David Brooks succinctly summed up, “The Republican Health Care bill failed because it was a bad bill that had almost no authentic public support. It took benefits away from tens of millions of vulnerable people in order to give tax breaks to the rich few.” It turns out that health care is too important and too personal to be used as a stalking horse for a big tax cut for the rich.

What Were They Thinking?

In hindsight, it is less remarkable that the American people soundly rejected this atrocious legislation and more surprising that its backers had the gall to bring it forward in the first place. However, despite this ignominious defeat, there is no indication that Trump or the Congressional Republicans have shifted into genuine problem-solving mode. They are still wedded to their narrative about how terrible the ACA is and unwilling to make peace with the idea that everyone should have access to affordable, meaningful coverage. Moreover, they are still scheming to bring another terrible repeal bill back to the floor or to undermine the ACA via administrative means.

No Time for a Victory Lap

In recent days, Speaker Ryan has indicated that he is not giving up his dream of cutting people off health care, which he has nursed since his frat-party days. And HHS Secretary Price has refused to commit to effective implementation of the law. Faced with all of these threats, there is a real risk that insurers will either pull out of the program or demand another big premium increase as a hedge against the uncertainty. Activists must be prepared to expose and push back against the next wave of attacks. But we must also do more.

Despite the gains made by the ACA, there are real problems in our health care system. These problems demand real fixes, not a toxic stew of tax cuts and ideologically driven nostrums that will make things worse, not better.

That means we need to advance policies to ensure adequate choice of plans, help the people who still cannot afford their premiums and reduce high cost sharing especially for people with chronic conditions that will cause them to hit their out-of-pocket maximum year after year. We need to confront the persistent racial disparities in health coverage and outcomes. We also need to address issues the ACA left unaddressed, such as high drug prices and inadequate coverage for services that allow older adults to stay in their homes.

Making progress on these fronts will require us to internalize two important lessons from recent events.

First, be prepared. While prospects for progressive action in Washington, DC and in many states may look dim right now, articulating a vision of what we are for and doing the policy work to back it up will help us make the most of opportunity when it arrives. Being prepared also means talking to the public to ensure that the proposals we advance have popular support.

Second, build unity. Democrats were greatly aided by their unity in opposition to AHCA, as were Republicans when they were in the opposition. However, building unity around what you are for is much harder than building it around what you are against, as we just saw. A lot of work went into building not just the policy but the political consensus that resulted in passage of the ACA and it extended far beyond elected officials. That consensus, which also led to the defeat of AHCA, included a broad swath of consumer, civic, faith and patient advocacy organizations, as well as most other health care stakeholders. We need similar unity now to advance solutions that address the real pressing problems we still confront.

The recent debate has shown that people are hungry for real solutions to their health care problems, not snake oil falsely marketed as “patient-centered” care. Our task in the weeks and months ahead is to build momentum for the former while continuing to defend against the latter.

Community Catalyst, Out2Enroll and health advocacy organizations across the country are marking National LGBT Health Awareness Week to bring needed attention to LGBTQ health disparities and to reaffirm our strong commitment to promoting LGBTQ health equity. Our celebration of LGBT Health Awareness week is extra sweet this year: Republican efforts to repeal the Affordable Care Act (ACA) and dismantle Medicaid – actions that would have had a devastating impact on the LGBTQ community – were thwarted last week after the House of Representatives decided not to proceed with a vote on the American Health Care Act. This news is a huge victory for LGBTQ individuals and their families, many of whom were at risk of losing access to high-quality, affordable health care coverage and critical consumer protections offered under the ACA.

While we savor our successes this week, we know more efforts to undermine the ACA are right around the corner. That’s why this year’s LGBT Health Awareness Week theme, ACT OUT for LGBT Health! Action on Health Access & Equity, is more important and relevant than ever. It is imperative that we speak out and take action to spotlight the incredible gains we have made in eroding LGBTQ health disparities thanks to the ACA. The ACA has helped many LGBTQ individuals access health insurance, get covered as a family, receive financial help to make coverage more affordable, and access covered health services, including transition-related care, for the first time.

LGBTQ Communities Continue to Benefit from the ACA

Last week, the Center for American Progress (CAP) released new research that explores in depth how the ACA continues to benefit LGBTQ communities. The coverage gains we have made under the ACA for LGBTQ individuals are nothing short of impressive: as CAP’s research highlights, “In 2013, before the ACA’s coverage reforms came into effect, one in three LGBT people making less than $45,000 per year (34 percent) were uninsured. Just one year later, in 2014, uninsurance for this group had dropped by one-quarter to one in four (26 percent), and by 2017, CAP’s study finds that it was around one in five (22 percent).” In short, the uninsured rate among low and middle-income LGBTQ individuals has dropped by 35 percent since the ACA became law.

Not only has the ACA significantly increased the number of LGBTQ individuals and their families with health insurance coverage, but the law also provides more affordable coverage options through subsidies on the health insurance Marketplace and through expansion of Medicaid. Access to affordable health care coverage is particularly critical for LGBTQ people. Because of a long history of oppression and discrimination, CAP’s report points out that LGBTQ people, particularly LGBTQ people of color and transgender people are more likely to live in poverty and earn less than non-LGBTQ people. CAP’s research shows that access to financial assistance on the Marketplace or through Medicaid helps LGBTQ individuals and their families feel more confident that they can afford regular and major medical costs. The ACA also requires health insurance plans to cover certain essential health benefits important to the LGBTQ community that ensure coverage of critical services such as HIV testing and mental health screenings.

The ACA (and its protections) remain intact, for now.

While the ACA remains intact and LGBTQ people are still protected from discrimination in health care and health insurance, we must stay vigilant as health care debates continue in Congress, the White House and at the U.S. Department of Health and Human Services (HHS). Harmful changes to the ACA not only come in legislative form like the failed American Health Care Act but significant changes can also emerge through executive action and regulatory reform. For example, just last week HHS eliminated questions about LGBTQ older adults and LGBTQ people with disabilities from two surveys, the National Survey of Older Americans Act Participants and the Annual Program Performance Report for Centers for Independent Living. This data provides HHS with critical information on the effectiveness of its programs and helps HHS identify persisting health disparities among people in the LGBTQ community. The Trump Administration also rejected a proposal to collect data on LGBTQ people in the 2020 census. We must continue to speak out and act when harmful policies like these are proposed by decision makers in Washington.

We celebrate this year’s LGBT Health Awareness Week with great pride and accomplishment. Over the last four months, millions of people across the country came together to tout the benefits of the ACA and oppose any measures that would cut coverage or result in higher costs for consumers.  We made our voices heard by gathering at rallies and Town Hall events, calling and writing to our legislators and getting active on social media. The failure of the American Health Care Act and our victory last week should remind us that when we #ActOut for our health care, we can make an enormous difference. This week, the LGBTQ community and our supporters need to continue to #ActOut4LGBTHealth and show that the ACA is working for LGBTQ people and their families.

The guest blogger for this piece is Katie Keith; Katie is a member of Out2Enroll's Steering Committee

Racial and ethnic health disparities persist in our nation and health care system. Compared to their white counterparts, people of color are more likely to be without health insurance. They often receive poor quality care and experience worse health outcomes. The causes of these disparities are complex and interrelated, and include social and economic determinants (such as income level, education, and living conditions in homes and neighborhoods) as well as racial biases and structural racism within the health care system and society. The Affordable Care Act (ACA) included a number of provisions to address health disparities including anti-discrimination requirements, essential health benefits and essential community providers—all aimed at more equitably providing coverage and access to needed care, but it did not eliminate all disparities. We still have far to go in eliminating health disparities but the GOP replacement plan, the American Health Care Act (AHCA) would be a giant step in the wrong direction that would further harm vulnerable populations.

Despite the growing fears and mounting opposition from many communities across the country to the dismantling of the ACA, the Trump administration and Republicans in Congress are determined to push through their vision of health care. The AHCA will undo the extraordinary progress we have made over the past six years. As Richard (RJ) Eskow, Contributor to the Huffington Post, rightly puts it, this bill is “an assault on people of color,” as it would “cut programs that disproportionately help people of color while providing tax cuts for the wealthy that disproportionately help white people.” According to the analysis released by the Congressional Budget Office (CBO) on March 13, as many as 24 million people would lose their health care coverage by 2026, and people of color would be among the hardest hit. Below are three ways the AHCA harms people of color.

1. Massive cuts in Medicaid would cause millions of people of color to lose coverage

Medicaid plays an important role helping to fill some of the gaps in private coverage, as people of color are more likely than whites to be in low-income, low-wage jobs that provide limited access to employer sponsored insurance (or if offered, require employee premium contributions that are too expensive and beyond their reach). However, one of the most outrageous aspects of the House Republican repeal bill is its deep cut of 880 billion dollar cut in federal funding for Medicaid over ten years. This is due to the reduction in federal funding for Medicaid expansion and conversion of the program to a per capita cap. Such a significant reduction in funding would put at least 14 million low-income Medicaid enrollees at serious risk of becoming uninsured and losing access to the care they need.

A rollback of Medicaid expansion would cause, for instance, as many as 1.5 million Blacks to lose coverage; similarly at least 440,000  American Indians and Alaska Natives would become uninsured; and the vast majority – 3.3 million – of women of color would be at risk of losing Medicaid expansion coverage and access to reproductive care services. Many people of color who face serious physical and/or mental health problems, including being overweight or obese, having diabetes or cardiovascular disease and experiencing frequent mental distress or substance use disorders would have efforts to treat and prevent these conditions undermined by the loss of coverage. For children of color, capping Medicaid means denying them access to important preventive services (including but not limited to preventive and developmental screenings and chronic care management for health conditions such as diabetes or asthma) provided at school-based clinics. A Medicaid per capita cap would exacerbate disparities in health outcomes between white children and children of color. Capping Medicaid funding will result in lower provider rates, reduced access to care predominately in communities of color and low-income communities, and separate and unequal health care systems.

2.  Marketplace coverage will cost people more as subsidies and cost-sharing benefits decrease dramatically

In addition to Medicaid coverage loss, approximately 12.2 million people – 30 percent of those are people of color – who are currently enrolled in the marketplace would find coverage unaffordable and would see their out-of-pocket costs significantly increase due to a decrease in financial assistance. According to the Center for American Progress, virtually everyone would experience an average cost increase of $3,174 in 2020 if the House Republican repeal bill passed into law; those with income below 250 percent of the federal poverty line would see their costs increase by $4,815; and the impact would be severe for older individuals age 55 through 64 as they would be forced to pay five times more than younger adults. People of color, especially Blacks and Latinos, would more likely fall into the lower-income range than their white counterparts. This financial impact would erode their financial stability – many of them have already struggled with medical bills. Facing financial burdens, many would forego needed treatments or medications, which would further deteriorate their health outcomes.

3.  Eliminating the Prevention and Public Health Fund Would Cut Supports to Low-income and Vulnerable Communities

Furthermore, the House Republican repeal bill would eliminate the Prevention and Public Health Fund (PPHF), which would directly affect everyday Americans and their families. On average, people of color experience shorter life spans, higher infant mortality rates and higher prevalence of many chronic conditions compared to whites. Much of the PPHF have granted to low-income and vulnerable communities, like West Bronx in New York as well as many other communities across the country, to expand preventive health programs such as diabetes awareness classes, infectious disease research, toxic lead eradication, mental health and vaccination efforts, and community bike plans. According to the Centers for Disease Control and Prevention, PPHF dollars have proven successful improving physical activity and childhood immunizations, lowered hospitalizations for preventable conditions, and increased prenatal care visits in their target communities. Eliminating PPHF would make the fight to close the racial health gap even harder.

We must continue to be loud and united!

Community Catalyst and the Health Equity Leadership and Exchange Network recently hosted a webinar in which Daniel Dawes, author of 150 Years of ObamaCare, and Dara Taylor of Community Catalyst discussed the impact of the AHCA on health equity and strategies we can use to protect our care and combat health disparities. The presentation can be found here. Some of the strategies shared were that, first and foremost, it is essential for us to work toward addressing systemic racism and to explicitly name it as “a cause of poor health.” Secondly, data collection is an effective tool to identify health disparities. We should work with state and local government agencies across sectors, health care providers and community leaders to collect as much health data as possible. In addition to race, ethnicity, sex, language and disability status, we should collect information related to gender identity, sexual orientation and income level to help answer research questions, test hypotheses and evaluate outcomes that lead to reducing and eliminating health inequities.  Lastly but not least, whenever possible, let’s make sure to elevate the voices of the people who will be affected in communities of color. Nothing is more powerful than hearing stories of how the ACA has positively improved health outcomes and provided financial security for millions of Americans. We must continue to work together in advocating against Republican repeal efforts that threaten to strip coverage away from millions of people and fails to advance health equity.

1. The per capita cap financing scheme burdens state budgets and harms children and families.

The House bill dramatically alters Medicaid’s financing structure. This restructuring would reduce federal funding, shifting the majority of the cost burden to states. As a result, states would be forced to ration important benefits for low-income children and families, placing their health and wellness at risk. These benefits include important access to preventive screenings to keep kids healthy. Roughly half of the 72 million enrolled in Medicaid around the country are children and almost 60 percent of children with disabilities rely on Medicaid for coverage and access to necessary health services.

Medicaid is a key tool to advance health equity. A Medicaid per capita cap would exacerbate disparities in health outcomes between white children and children of color. Capping Medicaid funding will result in lower provider rates, reduced access to care predominately in communities of color and low-income communities and separate and unequal health care systems.

2. The bill eliminates coverage for certain low-income school aged children and denies them access to important preventive services including vision, hearing and dental.

Children ages 6-19 are at risk of losing Medicaid coverage. The House bill reverses a requirement to cover all children under 19 up to 138 percent of the federal poverty level and allows states to roll back eligibility for school-aged children from 6-19 to pre-ACA levels. This would translate into higher costs for families and fewer benefits for school-aged children—namely, Early Periodic Screening, Diagnosis and Treatment (EPSDT)—an important set of benefits that ensures that children and adolescents receive appropriate preventive, dental, mental health, vision and developmental services. 

Children of color will disproportionately be hurt. For black children who are 6 times more likely to attend a high poverty school than their white peers, Medicaid is a lifeline that can help students access eligible health services inside school walls. These services include, but are not limited to, mental health services, substance use disorder screening and chronic care management (such as diabetes and asthma care). For children with disabilities, the risk, too, is great. Many school-aged children with disabilities require health services in school in order to participate and thrive. Rolling back access to Medicaid coverage threatens children’s health and long-term success.


3. Higher out-of-pocket costs combined with reduced tax credits bar families from accessing affordable coverage.

Higher cost-sharing and premiums force families to make difficult decisions about accessing care and making ends meet at home. For moderate-income families, the reduction in tax credits would make coverage out of reach. Over 1 million children rely on health coverage through Marketplaces and a cut to tax credits will impose an additional financial strain on parents. If the bill were enacted today, estimates show that families’ costs would increase by over $2,000. For families with income below 250 percent of poverty, costs would increase by over $6,000 on average. By 2020, when many provisions of the bill kick in, costs would increase by over $4,000 and over $9,000 for those living below 250 percent of poverty. These hikes in costs would be unsustainable for families.


4. Parents cannot access needed benefits to stay healthy and care for their children.

Healthy parents are able to care for their children, helping ensure that they thrive and become healthy adults. Winding down the Medicaid expansion would punish adult caregivers by limiting their access to needed care. The House bill would phase out the ACA’s Medicaid expansion by restricting current federal reimbursement to only continuously covered individuals. If Medicaid expansion enrollees experience a gap in coverage, the federal contribution reverts to pre-ACA levels. In addition to financially starving the program, the House bill strips down the benefit package by sunsetting the essential health benefits package for the Medicaid expansion population only.

The Medicaid expansion benefit package currently provides mental health and substance use disorder services as a core benefit. Eliminating these needed services puts families at risk, denying parents a pathway to good health and family unity. It is well-documented that when parents are healthy and have access to coverage their children are also more likely to be covered.


5. Cuts to Medicaid will have a ripple effect on state budgets and stunt innovation.

Healthy communities rely on more than just access to health coverage but also equitable access to safe neighborhoods, robust public schools and affordable housing. States work to balance the needs of their residents to ensure they can leverage multiple programs and resources to raise healthy families. Forcing states to shoulder the financial cost of Medicaid means that other important budget items would need to be reduced. These could range from public school budgets to public safety priorities. According to Center on Budget and Policy Priorities, per capita caps would shift $370 billion in costs to states over ten years. The House bill would also eliminate funding for the Prevention and Public Health Fund which would result in detrimental cuts to core public health programs including disease tracking, access to immunizations for low-income individuals and the prevention of and response to lead poisoning.

With a rise in cost burden, states would not have any funds to invest in innovative models of care that lead to smart program savings across the health care system. Medicaid coverage and adequate funding are the foundation for innovation, including testing methods that reward value instead of volume and address social determinants of health. The House bill’s per capita cap proposal would slash total federal Medicaid funding. Rather than increasing innovation, funding cuts due to per capita caps would hinder innovation and may even prevent it altogether.

As February comes to a close, we want to pause and recognize Black History Month. Often Black History Month is accompanied with celebrations of history and accomplishments of black Americans. Many of these opportunities are the result of continued advocacy for civil rights and equity in labor, education, transportation, housing and health. Within this spirit of equity and advocacy, Community Catalyst is committed to weaving a health equity lens into our entire advocacy and programmatic work. Our vision of health equity is to create a society in which everyone has a fair opportunity to achieve their full health potential, regardless of the individual’s or population group’s race, color, religion, national or ethnic origin, immigration status, class, age, disability, veteran status, sexual orientation, gender, gender identity or gender expression.  

As we strive to achieve our vision of health equity, we must recognize the current reality of the health outcomes that black Americans face. Health outcomes can be impacted by number of different factors, from individual behaviors to systemic influences – the latter often referred to as social determinants of health, “the structural determinants and conditions in which people are born, grow, live, work and age.” They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care. Unfortunately, black communities have shown significant disparities across a number of health outcomes for many years. And many of these disparities are a result of inequities within structural systems and social determinants of health. Some cases in point: African American babies are twice as likely to die before age one as white babies; 73 percent of black children are more likely to be obese than white children; 60 percent of black adults are more likely to have diabetes than white adults.

Health disparities are detrimental to the health of our communities and country. Poor health outcomes in any group lead to poorer overall outcomes in our society’s educational attainment and economy. In order to understand the existing disparities among racial and ethnic communities and find effective solutions, we need to ensure that policies are in place that require the collection and reporting of data on disparities. Inadequate health data can mask unique patient and population needs and undermine effective interventions. In complete opposition to the goal of gaining more insight on disparities, a bill introduced in Congress last month specifically restricts using Federal (HUD) funds to "design, build, maintain, utilize, or provide access to a Federal database of geospatial information on community racial disparities or disparities in access to affordable housing." Bills like this are harmful to low-income communities of color and push our society backward rather than forward towards health equity.

As we continue to think about advocacy efforts to defend the Affordable Care Act and Medicaid, it’s also very important for advocates to consider the implications and impacts harmful policies can have on vulnerable communities.  Under the ACA, the uninsured rates for blacks dropped from 21 percent in 2013 to 13 percent in 2016. In states that decided to take up Medicaid expansion, blacks are less likely to be uninsured.  Defending the ACA and Medicaid is more than just defending access to coverage; it is about protecting human rights and moving towards realizing our vision for health equity.

Reflecting on Black History Month reminds us not only of the fights of the past, but of the continued fight forward for equity.

On January 30, 26-year-old Vadim Kondratyuk of California, a father to two small children, died from a dental infection that spread to his blood and his lungs. Tragically, Vadim is not alone. Each year, millions of people go without treatment to their oral diseases, the effects of which can range from toothaches and pain to death. Ten years ago the death of Deamonte Driver, a 12-year-old who died from a dental infection that spread to his brain, galvanized oral health advocates around the need to improve access to dental care. Both Vadim and Deamonte’s deaths were preventable with access to affordable dental care. Without access, many of our friends, family, neighbors and children are at risk.  

Threats to Oral Health Care

Oral health is essential to overall health yet dental disease impedes daily life, including people’s ability to eat, learn and find employment. Congressional Republicans and the current administration’s efforts to repeal the Affordable Care Act (ACA) without a replacement plan in place and discussions of cutting Medicaid funding through block granting or per capita caps put millions at risk. In the seven years since the passage of the ACA, 22 million Americans, predominantly those in underserved communities, have gained new access to health and, in some cases, oral health care.  

Repeal of the ACA, especially without a replacement plan, would reverse this growth in coverage by dismantling the 23 oral health provisions established in ACA payment, delivery and workforce issue changes. This would roll back expansions to health and dental care, resulting in one less mechanism for dental coverage for a population that has seen huge disparities in dental disease, shift costs back to families both inside and outside the Marketplaces, and eliminate health and dental coverage for newly insured Americans.

But that is not the only threat to oral health coverage. Discussions of cutting Medicaid funding through block granting or per capita caps put health coverage at risk for 73 million of the most vulnerable members of our society including children, older adults and people with disabilities. Currently, full dental benefits to adult Medicaid enrollees vary from state to state but are required for children either through Medicaid or the Children’s Health Insurance Program (CHIP). Learn more about the impact of proposed changes in this fact sheet and webinar.

Some Communities Will be Hit Hard by Proposed Cuts

Oral health disease, which is largely preventable, is the most common chronic disease in children - five times more common than asthma – and affects communities of color at disproportionate rates. For example, in 2015 the National Health and Examination Nutrition Survey found that Hispanic (46 percent) and non-Hispanic Black (44 percent) children younger than eight years of age are more likely to have cavities than non-Hispanic White children (31 percent). The inability to access dental services also affects the vulnerable, the underserved, and communities of color at disproportionate rates.  Even with all of this data, oral health funding is often still one of the first programs to be cut during difficult financial times.

There is mounting evidence linking poor oral health with poor overall health outcomes. Good oral health is critical to overall wellbeing, but without access to oral health care we are all only one step away from being in Vadim’s and Deamonte’s shoes. To prevent a dental crisis we must defend the gains we made through the Affordable Care Act and push to make oral health care more accessible in our health care system.

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

Thanks to the Affordable Care Act (ACA), the uninsured rate in the United States declined to 8.6 percent in the first quarter of 2016, the lowest level on record. Approximately 22 million adult Americans have gained coverage through the ACA’s insurance Marketplaces and Medicaid expansion, in those states that proceeded with it. In addition, more than 3 million children have gained coverage since the ACA’s enactment, cutting in half the rate of uninsured children. Coverage gains are strong across all racial and ethnic groups, with a decline of 6 percent in the uninsured rate among whites, 10.3 percent among African-Americans, and 11.5 percent among Hispanics.

With this large decline in the number of people who are uninsured, states have seen significant budget savings and revenue gains. Over the last six years, changes deriving from the ACA have bolstered state economies and created more jobs in the health sector. According to a recent compilation of national and state-level data released by the U.S. Department of Health and Human Services, states have experienced a $7.4 billion decrease in hospital uncompensated care costs, the unreimbursed cost of the care provided by hospitals to people who are uninsured or underinsured. States that have expanded Medicaid have seen their uncompensated care costs fall by a total of $5 billion. Conversely, states that failed to expand Medicaid lost out on an estimated $4 billion in savings. In addition, Medicaid expansion states continue to report state savings in other areas, such as in behavioral health and criminal justice.

Unfortunately, despite these undeniable achievements, President Trump and the Republican-led Congress have already begun efforts to dismantle the ACA.  Through use of the budget reconciliation process, virtually all of the ACA’s coverage accomplishments (i.e., Medicaid expansion and tax credits for Marketplace coverage), and the revenue that helps fund them (i.e., the penalties associated with the individual and employer mandates), could be repealed early this year. And just a few hours after taking the oath of office at the Capitol, President Trump signed an executive order to give federal agencies the power to unwind regulations the ACA created. Up until now, the Republicans have failed to put forward a detailed replacement plan, and it could be years before they will enact a new plan. There is absolutely no doubt that eliminating the ACA’s coverage successes without a meaningful alternative approach will force millions of hard-working Americans to lose their insurance, as well as put state budgets at risk.

What states stand to lose:

States would experience a skyrocketing increase in uncompensated care spending over the next decade.

According to a new Urban Institute study, if a reconciliation bill passes, an additional 29.8 million people would be without coverage. Over 75 percent of those would become uninsured because of the elimination of Medicaid expansion, federal financial assistance for Marketplace coverage and elimination of the individual mandate, leading state and local governments as well as health care providers to experience an estimated $1.1. trillion in uncompensated care spending over the next decade.

States would lose billions of dollars in federal funding for Medicaid expansion

Although there is no consensus on a replacement plan, prior “repeal and replace” bills and proposals included elimination of Medicaid expansion. Let’s take a look at last year’s H.R. 3762, a budget reconciliation bill that was passed by both houses of Congress in 2015 but vetoed by President Obama in early 2016. This bill called for the complete elimination of Medicaid expansion for adults with incomes up to 133 percent of the federal poverty line as, well as enhanced Federal Medical Assistance Percentage (FMAP) for newly-eligible adults. According to a Manatt analysis, 31 states and Washington D.C. received an estimated $56 billion in federal funding to expand the program in calendar year 2016. Without the enhanced FMAP, the majority of expansion states would be forced to close their programs, leaving more than 11 million low-income adults without coverage. Medicaid cuts would be bad for state economies, and drastically reduce their ability to provide needed services for their most vulnerable residents (including expectant mothers, children with special health care needs and people with disabilities).

Quotes on State Budgets and the ACA

Repealing the ACA without an alternative approach would lead to state budget shortfalls as a result of a sharp reduction in federal funding. According to the Commonwealth Fund, ACA repeal would result in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs across all states. Over the next 10 years, states would see a cumulative loss of $1.5 trillion in gross products and a $2.6 trillion reduction in business output.

Governors, state Medicaid directors, and state budget officers have a lot at stake if the federal government pushes major health care cost increases onto states. Now more than ever advocates should urge state policymakers to speak out loudly against the repeal of the  ACA because of the damage that will be done to hard-working Americans and state economies.

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)

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