Posts About Health Equity

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)

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 NYTimes.com 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.

This is the first blog in 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.

One of the great joys of my work over the last several years has been working with our advocacy partners from the disability community here in Massachusetts. It’s been through their eyes that I’ve come to deeply appreciate the essential nature of Medicaid and the Affordable Care Act to this population. That’s why I am deeply troubled that the results of one election could undermine critical aspects of the infrastructure that allows millions of people with disabilities to live independently and with dignity.

Just the Facts, Ma’am

So who is this population? According to a 2015 report from the Centers for Disease Control and Prevention, 53 million - or one out of every five - adults in the United States live with some kind of functional disability. This includes difficulty walking, seeing, hearing, remembering, doing errands, dressing or bathing. The report also revealed that Black and Hispanic adults were more likely to have a disability than White adults. Additionally, those with lower education and income levels, and those who are unemployed were also more likely to have a disability. And it’s because of this strong correlation between disability and poverty that we must look first at the major role Medicaid plays for the population.

Medicaid Matters… More Than Ever

Medicaid serves as a critical safety net for the 10 million+ kids and adults who qualify for the program on the basis of a disability. These people, who represent approximately 15 percent of all Medicaid beneficiaries, live with a wide range of physical, mental health and/or functional disabilities.

One of the reasons Medicaid is so critical to people with disabilities is its coverage of long-term services and supports (LTSS). Indeed, it is the only public or private program to cover LTSS.  And increasingly these services are being provided at home or in the community, rather than in institutions. Home and community based services allow people with disabilities to live independently in their homes and with dignity. It also allows them to maintain relationships and pursue meaningful work. This is what’s required by law and what’s desired by the vast majority of beneficiaries with disabilities.

As critical as Medicaid has always been to people with disabilities, the ACA provided new and faster pathways to eligibility. This has been particularly true in the 32 states that expanded Medicaid thereby allowing even greater numbers of people with disabilities to enroll in the program.

Innovation Nation in Peril?

With the creation of the Center for Medicare and Medicaid Innovation through the ACA, The Centers for Medicare and Medicaid Services (CMS) began investing in targeted experiments aimed at achieving the Triple Aim: better care for the individual, better care for the population and lower health care costs. For people with disabilities, this has meant the opportunity to have better coordinated care and improved access to LTSS that prevents unnecessary hospital and nursing home admissions. Examples of ACA-sponsored innovations that benefit people with disabilities include:

  • The Dual Eligible Demonstration Projects: Through this initiative, CMS is working with states to test two models to integrate primary, acute, behavioral health and long-term services and supports for Medicare-Medicaid enrollees and better align the financing of the Medicare and Medicaid programs.
  • Initiative to Reduce Hospital Readmissions Among Nursing Home Residents: This effort aims to improve the quality of care for people residing in nursing homes by using evidence-based clinical and educational interventions with the goal of reducing avoidable, and expensive, hospitalizations.
  • Community-Based Care Transitions Program: This program seeks to improve transitions of Medicare beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, reduce readmissions for high-risk beneficiaries and document measurable savings to the Medicare program.

The future of these and other innovations that improve care for people with disabilities and other vulnerable populations is most certainly in question.

Private Market Protections

Finally, for people with disabilities who have private insurance, several well-known (and popular!) ACA provisions are particularly important. These include the prohibitions against:

  • denying coverage for any reason, including pre-existing health conditions
  • lifetime monetary caps
  • charging consumers different rates based on their health status or claims history

Additionally, the ACA added two key nondiscrimination provisions that provide important protection for people with disabilities in the individual and small markets, namely:

The Bottom Line: Nothing About Us Without Us!

The results of the 2016 election create new threats to some of the most fundamental supports that the tens of millions of people with disabilities in our country rely on today. Together, we must work to protect Medicaid and Medicare and the continued investment in delivery and payment reforms that seek to improve the programs rather than tear them down. The rallying cry of the disability community, “Nothing About Us Without Us,” is particularly fitting as we enter the fight of our lives: for health care justice.

One curious feature of our current moment in health policy is how divergent the impending course of action pledged by Republicans in Congress and the incoming Trump administration is from the preferences of major health care industry stakeholders. Dominant models of public policy making assume that the preferences of large economic stakeholders in a given policy area will exert a lot of sway over the outcome. To be sure, every interest group has something(s) they want to change about the Affordable Care Act (ACA), but there is very little appetite among providers, hospitals or insurers for rolling back coverage. For example, a recent survey in Modern Healthcare found overwhelming opposition from health care CEOs to repealing in the ACA without a replacement at the ready. Yet that is the course the Congressional Republicans seem ready to embark on – inflicting serious pain in the process, especially on providers (not to mention the millions of Americans who stand to lose coverage).

It seems hard to imagine a parallel in any other industry. (Of course, the banking industry didn't exactly love the Dodd-Frank bill, but its passage was only made possible by the self-inflicted meltdown of the industry). The present situation is so unusual that it demands an explanation. I don't presume to be able to peer into the minds of the repealers, but I think there is some combination of three things going on:

  1. Ideological extremism. An anti-government ideology is so profoundly held within most of the Republican leadership in Congress today that pursuing fervently desired goals is totally unmoored from considering any real-world consequences. Thus, the ACA must be repealed “because-government.” The real-world harms – the rise in medical debt and personal bankruptcy, the erosion of hospital finances, the increases in mortality – are just not germane.
  2. Health care as "piggybank." The money for touted big tax cuts for the wealthy and increased military spending has to come from somewhere. With federal discretionary spending already pared to the bone, there just isn't another major source of money beside the health realm to tap in order to pay for these "more important" priorities.
  3. “The dog catches the car” problem. For years, Congressional Republicans have been able to score political points railing against the ACA and passing veto-certain repeal measures without having to deal with the pesky problem of figuring out what would come after. The election of Donald Trump caught pretty much everyone by surprise, but it is far too late now to moderate the rhetoric. Repeal has been repeatedly promised and now, with control of both houses and the presidency, come January, the promise must be fulfilled regardless of the problems it might cause. There is no room for backtracking.
 

Are Republicans Serious About "Replace"? We'll Find Out Soon

To be fair, there are some real ideas out there on the Republican side about how to replace some provisions of the ACA. For example, various policy makers and conservative academics have proposed a variety of alternatives to the individual responsibility requirement, including continuous coverage, auto-enrollment and late enrollment penalty. Different ways to design financial assistance and minimum coverage are also possible (not to say that these alternatives would work better than the ACA). The problem is how these ideas interact with the "piggybank" scenario (see #2, above). Any serious alternative requires money. If the first thing the new Congressional leadership and incoming president do is pull a ton of money out of the system, it will be an early sign they are not serious about health policy and that repeal is just a stalking horse for transferring wealth up the income scale.
 

Now Is the Time to Speak Up!

It cannot be overemphasized that the threat to create chaos in health care for millions of Americans extends far beyond proposals to roll back the coverage gains made by the ACA. Enormous cuts to Medicaid are also on the table. Even Medicare is not safe, a fact underscored by the recent comments of Representative Tom Price, thought to be a leading contender for the top job at Health and Human Services under a Trump administration, who confirmed that the efforts to overhaul (aka cut) Medicare would begin in 2017. It is fair to say that there is no electoral mandate for these cuts to Medicaid and Medicare, but the American people may very soon find these programs at risk, nonetheless.

The takeaway is that while the ACA may be first on the chopping block, Medicaid and Medicare will follow closely behind unless we mobilize now to save these vital programs. Members of Congress are saying they aren't hearing from people complaining about repeal, so it’s crucial for all of us to raise our voices loudly right now.

This is the first in a series of blog posts that will share Community Catalyst’s vision for achieving health equity in the U.S. health care delivery system.

Since the introduction of the Affordable Care Act, the uninsured rate has dropped by over 50 percent for African Americans and by over 25 percent for Hispanics. These figures indicate meaningful progress in coverage, but there is much more that needs to be done to move toward truly equitable access to care and quality of care received. Here at Community Catalyst, we recently reexamined and revitalized our vision of health equity. We see health equity as the realization of a state in which everyone, regardless of their geographic location or demographic profile, can attain the best possible health outcomes. We believe that our country can attain health equity through constant and wide-ranging transformational efforts focused on the systems and institutions that have created historical and contemporary injustices in our society.

The health equity vision at Community Catalyst is based on the following five guiding principles:

  1. Reduce health inequities/disparities: Health inequities/disparities are those differences in health outcomes between population groups that are avoidable, unfair and unjust.

  2. Eliminate barriers to quality care: Advocating for adequate access and robust benefits that support culturally and linguistically competent care is necessary to break down the barriers that have prevented some groups from receiving quality care or from seeking care in the first place.

  3. Address structural injustices: Explicit recognition of the role of institutional injustices/discrimination, particularly structural racism, in driving health inequities/disparities, and taking steps to transform this dynamic within the health care system, is necessary to improve the quality of care for marginalized communities.

  4. Promote meaningful engagement from diverse consumers: A diverse consumer base must be mobilized and empowered to ensure everyone’s health needs and concerns are being acknowledged and addressed.

  5. Foster leadership: Underserved communities across the United States have pent up leadership potential that is uniquely positioned to bring together the voices of their communities and advocate for the needs, interests and concerns of their community.

These guiding principles were rolled out to the Community Catalyst staff as part of a thought exercise in which examples were solicited of the ways in which the organization strives to put these principles into practice. These examples were collected from the staff over the course of five weeks. This blog series is a culmination of the responses we received, and will consist of five posts following this one, covering one of our health equity principles in each. Each blog will include an explanation of the Health Equity principle from a Community Catalyst perspective, an example of our work within the context of that specific principle, and a brief interview with a staff member involved with the example.  In the coming weeks we welcome you to join us as we explore what more can be done advance health equity.

Shruti Shantharam
Health Equity Intern

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