Ensuring that families of all ethnic backgrounds access the health care they need to be healthy is one of the most important things we can do for our nation’s children. We at Children’s Defense Fund-Ohio (CDF-Ohio) recently released a new report, Reaching Ohio’s Ethnic Minority Children, outlining strategies for getting more ethnic minority children and pregnant mothers the health care they need. 

In Ohio, approximately 140,000 children lack health insurance. Of those, about 73 percent are eligible for, but not enrolled in, Ohio’s Medicaid program. These children could be accessing free health coverage, but they’re not. CDF-Ohio has long been concerned about the fact that children of color, children in low-income families, children with disabilities, and other marginalized children disproportionately lack access to health care. This impacts their health both in the present and throughout their lives. Within the communities of color we advocate for in Ohio, the marginalization is exacerbated for children who belong to ethnic minority populations – particularly populations with Limited English Proficiency. CDF-Ohio’s new report provides a snapshot of the Asian, African, and Latino populations in Ohio, and makes culturally-competent, community-driven recommendations about how to more widely enroll children and ensure that they are using their health coverage. This is an important next step in identifying and fighting health disparities and improving health outcomes for children in Ohio – and in other states across the country.

Many Ohioans don’t know that Columbus, Ohio’s biggest city, is home to the second largest population of Somali immigrants in the United States. Ethnic African families frequently relocate to Ohio. Reaching ethnic minority populations like Columbus’ Somalis, or the significant Burmese population in Akron, for example, requires community-driven, targeted outreach. Recommendations from the report include:

  • Training bilingual outreach workers who are members of the targeted communities and are familiar with a region’s individual needs. For example, the Ohio Hispanic Coalition’s Promotoras de Salud program trains health advisors to assist their neighbors on how to access health care services. The focus of the promotoras is to ensure that immigrants with limited or no English proficiency receive assistance and guidance.
  • Providing enrollment and health care information at existing social service programs, such as English for Speakers of Other Languages (ESL) classes and after school programming. In Cleveland, Asian Services in Action operates after school programming for children and disseminates needed information and materials to parents at pick up and drop off, or in children’s school materials.
  • Working with trusted community institutions. Somali mosques and the imams who lead them are a key source of disseminating information and messages – working with them is a much more efficient way to spread information to the Somali community.
  • Looking to other states’ successes – and failures – and learning from those lessons. The report contains a section highlighting some outreach efforts targeting ethnic minority communities in other states. For example, Farmworker Justice in North Carolina partnered with four community-based organizations to start a campaign that connects rural Latino families to Medicaid and CHIP.

A primary takeaway from this work has been that statewide advocacy organizations, like ours, cannot effectively lead outreach and education efforts that target ethnic minority and immigrant populations without directly engaging with and building on expertise and relationships with community-based organizations. They know the institutions, alternative media sources, and community leaders who can best connect with the families who need to be reached, and they are necessary to building and maintaining trust in communities.

We believe that we must work together with policymakers, other advocates, state agencies, and community-based partners to end health disparities and reduce the rates of uninsured children across the nation. Our report provides a starting place in Ohio, with concrete suggestions on how to reach marginalized families and children. We must start there, and then continue to organize to put policies in place that advance health equity and encourage a healthier and more just society for everyone.

Sarah Biehl
Children's Defense Fund - Ohio
Policy Director

Before new coverage options under the Affordable Care Act (ACA) rolled out in October of 2013, Washington CAN! mobilized to make sure the state accepted federal funds to cover low-income adults through Medicaid. Now, after two years of enrollment through the ACA, nearly 552,000 people are now covered by Medicaid, also known as Apple Health, and despite initial hiccups and stumbles with the online system our state had the fourth highest drop in the number of uninsured. Most people agree Washington’s efforts to close the coverage gap were incredibly successful.

Despite this evidence, Representative Cathy McMorris Rodgers (R), was determined to paint a different picture. She asked her Facebook followers to share negative stories to bash the Affordable Care Act (ACA). However, instead, her post received an overwhelming response from nearly 10,000 fierce defenders of the ACA. Many of their comments indicated that either they or family and friends benefit from the new health care options under the ACA, including Apple Health. It was heartening to see so many Washingtonians stand up for health care coverage and for their friends and neighbors.  

At Washington CAN!, we know the thousands of positive comments on Representative McMorris Rodgers’ Facebook post represent the true benefit of covering more people. In our own outreach we heard similar things from people across our state. We heard from Sam, a University of Washington graduate student who told us that Apple Health has given her peace of mind as she finishes her degree and starts her job hunt. She was afraid of getting sick and having to choose between treating her illness and paying tuition. Now, she’s considering starting a family thanks to her Apple Health coverage.

We heard from Kristi Brown Wokoma, chef and owner of That Brown Girl Cooks, a small business. She and her husband were still paying the debt for a hospital stay to remove fibroids when another serious condition surfaced. They were covered by Medicaid because Washington accepted federal funds to cover more people through the program. Now they can take care of her medical challenges without losing ground financially. Wokoma is grateful her family is now covered.

As we see and hear about the importance of insurance coverage for people in our state, we know there is more work to do to make sure everyone has access to care. We organize with the idea that our members are a powerful representation of every consumer and encourage them to advocate for the best coverage possible.

At Washington CAN!, we believe the next step for Washington is universal single-payer health care. The Health Care is a Human Right movement, a two-year, grassroots campaign to give all Washington State residents access to quality affordable health care is underway. Two bills were introduced in the 2015 legislature and, because they heard from Washington CAN! members in their districts, 45 legislators were co-sponsors, an impressive number for a first-time bill. The campaign, built with a robust coalition, is off to a great start. So yes, Washington State has indeed benefitted from increased access to Medicaid and will continue to do so, but it’s only the beginning.

-- Rosalind Brazel
Communications Director
Washington Community Action Network

A half century seems like a good time to celebrate and take stock of Medicare and Medicaid—our two bedrock programs providing health security to millions of older adults, people with disabilities, children and low-income families. Not only did these programs open the doors to health and economic security to their beneficiaries, they have played an essential role in breaking down the (legal) segregation in our health care system and supporting major technological advances in health care. (An under-appreciated bit of Medicare history: prior to passage hospital wards were segregated, but hospitals had to desegregate in order to receive Medicare funds

As I reflected on this anniversary, what came to mind was this quote that is often attributed to Thomas Jefferson, but appears to actually have been said by the abolitionist Wendell Phillips: "Eternal vigilance is the price of liberty" and, he went on to add "power is ever stealing from the many to the few."

No victory is ever permanent. Once it has been won it must be defended, essentially forever. While ACA proponents aspire for the law to achieve the popular status of Medicare and Medicaid, just last week a major political figure mused out loud about the need to end Medicare (at least as we know it). Although both programs were passed with bipartisan support, there remains a segment on the far right that has never accepted them. If you are looking for speculation as to why you can look here and here.

Despite, and in part because of, their great achievements, the programs face serious threats and challenges that must be overcome if they are going to survive for another 50 years.

Challenges for Medicare

Persistent efforts to change the program from defined benefit to defined contribution are the biggest threat to the future of Medicare. That effort has two parts, one that may not undermine the program, but is well underway, and another that remains a right wing talking point (for now).

The first part of the original, and still active, plan to get Medicare to "whither on the vine" was to move people away from "traditional Medicare" and into a more privatized system. Medicare Advantage has been the vehicle for accomplishing this. Medicare Advantage plans’ deliberately higher payment rates have helped it become a firmly established program, with nearly one third of Medicare beneficiaries enrolled. While the ACA has dialed back those overpayments, for many beneficiaries, Medicare Advantage is simply the most cost-effective option.

The real prize for those who want to take down the program, is moving from defined benefit to defined contribution. Under a defined contribution scheme, instead of being guaranteed a set of benefits for no more than a certain cost, the federal government would make capped per-enrollee payments that could be used to purchase private insurance. Most analysts anticipate that the size of the federal payments would not keep up with the rising cost of health care, shifting more and more cost onto beneficiaries over time (indeed, this is a feature not a bug--it's how defined contribution saves money).

While opponents are active in attempts to destabilize Medicare, there is a competing vision for the future of the program. The goal is to progressively improve the quality and efficiency of the program, particularly for the sickest beneficiaries who use most of the program's dollars. Many ACA provisions—accountable care organizations, bundled payments, etc.are an effort to implement that vision and improve the long term affordability of the program from a budget perspective without shifting costs onto beneficiaries. These efforts, while in the early stages, offer the promise of both better care and lower cost.

Challenges for Medicaid

Medicaid is the program that everyone loves to hate but hates to cut. Federal budget hawks worry about the program’s cost and state officials struggle to fund the program while still paying for other state services. Providers regularly decry the low payment rates. But when it comes down to it, cutting Medicaid is generally an unattractive option for states facing a budget crunch. Since most of the savings from any cut go back to the federal government, Medicaid cuts represent a high pain, low gain approach to states managing budget challenges. And while providers grumble (and sometimes sue) over Medicaid rates, they are far better than nothing at all.

Again, there is a draconian vision for the future of Medicaida federal block grant to states that doesn't keep pace with rising health care costs. Such a block grant would come with few strings attached and leave beneficiaries increasingly unable to afford or access medical care.

While the block grant debate is perennial in Congress, less extreme, but more pressing challenges loom largely from the fallout from the Supreme Court decision that created the coverage gap. As states debate closing the gap, two main threats have emergedincreased cost sharing and restrictive eligibility rules.

The effects of cost-sharing on low-income people are clear and well known. Premiums will discourage enrollment and co-payment will be a deterrent to seeking necessary medical care. Notwithstanding these negative effects, some degree of cost-sharing is often supported even by proponents of closing the coverage gap. The principle of universal contribution has to be balanced against the potential for economic hardship--a point that too often gets lost in the policy debate where cost sharing is often wielded as a strategy to suppress enrollment and use.

The other threat, which has made no headway thus far under with federal officials, is to return Medicaid to its welfare roots (albeit with a twist). In 1996, welfare reform severed the link between cash assistance and health care but some state officials are trying to shoehorn Medicaid back into a welfare program (think work requirements) instead of allowing it to serve as the foundation of our nation's multi-layered coverage strategy.

If block grants, skimpy coverage, work requirements and financial barriers are one dystopian vision for the future of Medicaid, what about the other side? Is there a more positive vision?

Indeed there is. Like Medicare, there are efforts across the country to make Medicaid work better. Recent federal regulations are an effort to improve the quality of care for beneficiaries. As with Medicare, states are looking at ways to change how care is delivered and paid for to better and more efficiently provide care to high-need, high cost beneficiaries. The ACA has also created tools that can be used for more sweeping changes. Examples include the global budgeting waiver in Maryland and the now stalled single payer effort in Vermont. 

Can the more optimistic vision of the future of Medicaid and Medicare prevail?

It will not be easy. One challenge to the financial sustainability of both programs is the growing cost of prescription drugs (a topic for another day). However both Medicaid and Medicare remain popular at their 50th anniversary and are strongly supported by organized consumers and providers. If we remain vigilant, Medicare and Medicaid can not only survive for 50 years they can thrive and continue to provide people with access to care and financial protection over the long-term.

Fifty years ago this week Medicaid and Medicare were signed into law. These two programs provide children, seniors, people living with disabilities and working families with access to the health care they need. To celebrate 50 years of these two programs, each day this week one of our partners will share a story about their work to ensure more people can access Medicaid. We’ll also be reflecting on the two programs and what’s ahead. 

After the murder of nine African-Americans in a Charleston, South Carolina, church last month, Rev. William Barber, the President of the North Carolina NAACP and leader of the “Moral Mondays” movement, said, the best way to honor the legacy of Reverend Clementa Pinckney and the other victims, was to overturn voting rights restrictions and expand Medicaid eligibility. As we approach the 50th anniversary of Medicaid, Barber’s comments are of particular importance. Health care in North Carolina, and the country more generally, continues to be seen as a privilege not a right. But without health coverage, North Carolinians are more likely to see their health compromised, impacting both their quality of life and their mortality. Health care access, like low wages, is a measure of the inequality that is rending the fabric of our communities.

Rev. Barber draws attention to Medicaid because North Carolina is one of 21 states—11 in the Southern region of the U.S.-- that have refused federal funds allocated by the Affordable Care Act to provide health coverage to all adults living in households with incomes below 138 percent of the poverty level. Currently, Medicaid coverage in the state is restricted to extremely poor parents (household income below 40 percent of the federal poverty level or $667/mo. for a three-person family), pregnant women, and children. Nonelderly, nondisabled adults without dependent children are ineligible regardless of income.  About 500,000 North Carolinians could benefit from expanded Medicaid coverage, according to the North Carolina Justice Center. Of these, 300,000 have no other coverage option.

A recent paper from the Paraprofessional Healthcare Institute (PHI), “Too Sick to Care: Direct-Care Workers, Medicaid Expansion, and the Coverage Gap,” indicates that of North Carolinians who are affected by the Medicaid coverage gap nearly 10 percent are direct-care workers—the home health aides, personal care aides, and nursing assistants who provide support to the state’s elders and people living with disabilities. About 45,000 direct-care workers live in households with incomes below 138 percent of the poverty level. Moreover, 29,000 of these workers live in households with incomes below 100 percent of FPL. These workers fall in the “coverage gap”: they have no new options for health coverage under the Affordable Care Act, because they are ineligible for federal tax credits that make buying insurance on the state marketplace more affordable.

Direct-care workers provide 80 percent of the paid hands-on care for elders and people living with disabilities. As the recent profile in the Raleigh News and Observer documented, this is strenuous, emotionally difficult work that is essential to the dignity and health of North Carolinians who need assistance with personal care and other tasks that many of us take for granted. It seems particularly ironic that these care providers are forced to go without care themselves.

Medicaid coverage is especially important to North Carolina’s direct-care workers because fewer than one in two has access to an employer-sponsored health plan. In some cases, employers—whose primary revenue often comes from providing Medicaid funded long-term services and supports—don’t have the resources to offer affordable coverage; in other cases, erratic and part-time hours, which are typical for home care aides in particular, make workers ineligible for coverage. 

North Carolina, like much of the country, has an aging population. An additional 22,000 direct-care workers are needed by 2022 to meet the state’s eldercare needs. But finding and keeping workers is becoming increasingly difficult. It’s not surprising: wages are low, injury rates are high, and employer-sponsored health coverage is uncommon. The result is that one in two workers leave the field annually. Anyone who needs care or manages care for a family member knows viscerally what this means: a parade of ever-changing aides who lack experience and who don’t stay long enough to build the quality relationships upon which good care is built. It is tough on the family, and even tougher on those who depend on the care provided.

Closing the coverage gap in North Carolina is an opportunity to address multiple issues, from the economic and racial inequality Reverend Barber seeks to address to providing quality long-term care services. The latter has been on the agenda of North Carolina aging services for nearly a decade. The NC NOVA program awards long-term care providers for investing in training, mentoring, and other workplace innovations that improve the quality of direct-care jobs and, as a result, the quality of care. The state should take the next step and ensure that all direct-care workers have access to affordable health coverage---a healthier, more stable workforce is absolutely essential to meeting the needs of North Carolina’s elders and people living with disabilities.

Jodi M. Sturgeon, President, PHI
Thomas R. Konrad, Ph.D. 

Jodi M. Sturgeon is the president of PHI, a national nonprofit that fosters dignity, respect, and independence– for all who receive long-term care, and all who provide it. PHI is the nation’s leading authority on the direct-care workforce. This week, PHI released “Too Sick to Care: Direct-Care Workers, Medicaid Expansion, and the Coverage Gap,” which examines how the direct-care workforce is affected by state decisions not to expand Medicaid eligibility.

Thomas R. Konrad holds a Ph.D. in sociology and recently retired from the University of North Carolina at Chapel Hill, where he conducted healthcare workforce and workplace research for over 40 years, while at the Cecil G. Sheps Center and the North Carolina Institute on Aging. Dr. Konrad developed and evaluated training programs for direct care workers in various long term care settings and has conducted numerous studies of the impact of health care workforce development and workplace redesign on care outcomes with support from federal, state and foundation sources. 

Lyndon B. Johnson signing the Medicare bill. Fifty years ago today, President Lyndon B. Johnson signed into law the landmark amendments to the Social Security Act that created the Medicare and Medicaid programs. In his comments at the signing, President Johnson made explicit the connection between the right to health care, and the financial security of older Americans and families of all ages. In the half century since, these two life-changing programs have indeed provided that security to tens of millions of adults over age 65, people with disabilities, children and families, pregnant women, and low-income Americans.

At the time of enactment, roughly half of all older adults in the United States had no health insurance. Today, Medicare and Medicaid cover nearly 1 out of every 3 Americans – more than 100 million people. But there are still millions more without coverage of any kind, or with coverage, but inadequate access to care and services they vitally need.

While a pause for celebration is in order today, complacency is not.

The United States continues to spend almost twice as much per capita on health care as any other western democracy, with far less “bang for our buck,” in terms of health status and outcomes to show for it. Significant health disparities and unequal access to quality care continue to be hallmarks of our health system. These issues pose a threat to the sustainability of Medicare and Medicaid, as well as new programs established under the Affordable Care Act.

The ACA was carefully crafted to build upon – and improve – the solid footings Medicaid and Medicare provide for the health care of vulnerable populations, even as it created a new pathway to coverage for millions more through the insurance Marketplaces.

Beyond establishing the Marketplaces, the ACA has many other provisions that are already changing the health care landscape in dramatic ways:

  • First and foremost, the provision insuring more people through Medcaid was envisioned to take effect in every state, to dovetail with the eligibility guidelines of the Marketplaces. Advocates are working tirelessly in those states which have yet to close the coverage gap to make that promise a reality in all 50 states.
  • The Medicare-Medicaid Coordination Office, created under the ACA, is overseeing financial alignment demonstration projects in a dozen states to address the very real difficulties that people eligible for both Medicare and Medicaid confront daily due to the different rules and benefit guidelines, and often fragmented and uncoordinated care they produce. Our Voices for Better Health Project is working with state partners and geriatric provider experts to help implement these demonstrations to provide the best integration and coordination of care possible, while protecting consumers and helping them make their voices heard in the process.
  • The Center for Medicare and Medicaid Innovation (“The Innovation Center”) is another creation of the ACA. This center is working to seek out, evaluate and pilot new payment and service delivery models that aim to achieve better care for patients, better health for communities, and lower costs through improvement of the health care system.

There is much more advocacy needed to expand the reach, quality, equity and cost effectiveness of both Medicare and Medicaid in the decades ahead. Community Catalyst and our state partners are committed to working together to transform our health care system into one that operates effectively and efficiently to ensure all people get the care they need and that invests in keeping them healthy. 


For today, please join us in wishing a Happy 50th Anniversary to Medicare and Medicaid!