Posts About Coverage for the Uninsured

Movie sequels often fail to live up to the original, and Republicans' effort to repeal the ACA falls into this familiar pattern. As bad as the original was (and it was really bad), the sequel was even worse. Not content with taking health insurance away from 24 million people, increasing premiums and out-of-pocket costs for millions more, fundamentally undermining the Medicaid program, and shifting new costs onto states and providers, last week the Trump administration and House leaders continued to try to undermine health care coverage.

Fortunately, the revised proposal was quickly rejected and "pulled from the theatre." Republican lawmakers left town with nothing more to show for their flurry of activity than what appears to be a face-saving effort to get themselves out of the corner they painted themselves into when they attacked the idea of reinsurance as an "insurance industry bailout" by renaming it an "invisible high risk pool".

As much as this was a short-lived effort to bring the bill back to the floor, it contains two critical lessons:

First, if this was not already clear enough, President Trump's commitments on health care are meaningless. The huge gulf between his words and actions has been laid bare for everyone who doesn't have blinders on to see. Despite promising otherwise during the campaign, the original ACHA, which the Trump administration enthusiastically embraced, included a massive cut to Medicaid and even a cut to Medicare. It also undermined the insurance market reforms Trump promised to preserve by allowing states to waive Essential Health Benefits.

The EHB changes already in the AHCA would have undercut the ban on pre-existing condition exclusions by allowing the sale of insurance that excludes coverage for specific benefits or diseases while also exposing people to uncapped out-of-pocket charges. The proposed change in the rating rules would compound this by allowing insurers to charge people more based on their health status. These are devious proposals: while a guaranteed right to purchase would nominally remain, it would be virtually useless since insurers could charge sicker people such high premiums that coverage is priced out of reach.

Fortunately, the new deal collapsed for the same reason as the old one -- it was caught in a squeeze between the demands of the Freedom Caucus, which seeks an even more drastic rollback, and the outrage of an activated populace determined not to allow their health care to be stripped away.

Second, as in the typical horror flick, the monster can return from the dead multiple times. Despite the first failure, the House made a second effort, driven by the Trump administration, which again demanded they put a bill on the floor before April recess.

In a strange way, this abortive effort did us a favor. If anyone was feeling complacent after the collapse of the AHCA, the revived effort should have put people on notice. While the public outcry and GOP infighting have dealt ACA and Medicaid entitlement repeal a setback, the effort is far from dead. We should expect an effort to bring a bill back to the House floor in May, following the debate on spending for the remainder of 2017, which will occur in late April, and prepare accordingly. 

More Dragons on the Road Ahead

The AHCA, in whatever metastasized form, is not the only threat. Even if Republicans in Congress abandon a straight repeal effort, there are several other critical danger points. If, and when, Congress turns its attention to taxes, they are likely to need spending offsets to pay for (wait for it…) tax cuts for the rich. That could lead lawmakers back to looking at Medicaid (or the ACA) as a pay-for. Similarly, an effort to increase military spending might also create a hunt for spending offsets and put Medicaid and/or the ACA back on the chopping block. CHIP refinancing presents another "opportunity" for lawmakers predisposed to undermining the Medicaid financing structure.

Perhaps even more dangerous than these various legislative threats is the damage Congress and the Trump administration could inflict upon the ACA through both harmful actions and "malign neglect.” By creating a climate of uncertainty about the "rules of the road," including whether they will finance cost-sharing reductions and enforce the individual mandate, we can expect more insurance carriers to drop out of the Marketplace. This could leave more counties with only one option - and others with none at all (at least temporarily). Coupled with this uncertainty, and in the absence of action to improve the risk pool or a commitment to a robust enrollment push, we expect many insurers that stay in the Marketplace could seek another year of large rate increases. This could reverse the surge in popular support for the ACA and fuel the "ACA is broken" narrative.

To be very clear, ACA defenders are in a much stronger position after the defeat of the AHCA in the House, and there are plenty of things Congress or the states could do to lower premiums and cost-sharing and expand coverage, if they are so inclined. However, the bottom line is attacks on our health security are not going to subside any time soon. If people want to keep their health care, they are going to have to keep fighting to defend it. In other words, the only way to make sure this zombie stays in the ground is to keep shoveling dirt on the grave.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

As Republicans struggle to come to agreement on how far to go with ACA repeal and what to put in its place, they are confronted with three interlocking math problems: first, how to make their budget numbers add up; second, how to put together a proposal that can command a majority in both the House and the Senate; and third, how to avoid running afoul of public opinion.

Where to Start?

Let's start with the budget problem. The budget reconciliation instruction only requires Congress to save $2 billion over 10 years, which is barely even rounding error in the context of overall federal health spending. It should be easy, right? But the complications begin immediately with the Republican commitment to repeal the taxes that helped pay for the expanded benefits in the ACA.

How to plug that hole? In the good old days of "repeal and delay" (about a month ago), you simply wiped out all of the ACA spending – including both the tax credits for marketplace coverage and all of the Medicaid expansion funds – and made some vague promises about fixing it later, someday, maybe (not!). But “repeal and delay” ran aground on the other two problems – public opinion, which is strongly against it (only 18 percent support this course), and that constituents have not been shy about making their objections known to their members of Congress.

As a result, there aren't enough votes to pass repeal and delay, so GOP leadership is in need of some kind of replacement plan. That replacement plan has to make good on Republican commitments to preserve access to coverage for people with pre-existing conditions and also has to avoid yanking Medicaid coverage (and funding) away from states. But preserving funding for the Medicaid expansion (even if the federal matching rate phases down over time) and creating a substitute for the ACA tax credits, even at reduced levels, eats up some of your savings, so you are still left with a budget hole.

How big a hole depends on how much of the expansion funding is preserved and how adequate are the new tax credits. The greater the funding preserved, the bigger the budget hole. But proposals to shrink the funding have fueled opposition in states that have benefited from the Medicaid expansion, including 16 states with Republican governors. It would also cause the number of uninsured to spike and do little to allay the public's fear that people with pre-existing conditions will again be locked out of the insurance market. 

A notable feature of the recently leaked draft House repeal-and-replace plan is that it tries to address these problems by providing more funding for the Medicaid expansion and for subsidizing private insurance than did previous proposals, such as the one authored by now-HHS Secretary Tom Price. But because at least a portion of the ACA funding is preserved, a sizable budget hole remains, although we don't know how big because no CBO score has yet been made available.

Fixing a Hole?

How is this hole to be plugged? Again according to the leaked plan, there are two additional revenue sources. One, involves cuts to the core Medicaid program; the other involves changes to the tax exclusion for employer-sponsored insurance, in the sphere of the ACA's "Cadillac tax" that places an excise tax on the most expensive health plans. But both of these revenue sources immediately run into trouble with respect to math problems two and three, above. The "Cadillac tax" is wildly unpopular with both the public and in Congress, across party lines. It is not at all clear that a majority of members will repeal the Cadillac tax only to turn around and support replacing it with something that essentially does the same thing.

On the Medicaid front, the House proposal is to continue to provide states with enhanced matching funds through 2019, but only for those beneficiaries who are currently enrolled. New enrollees would receive only the regular match rate. Starting in 2020, states would receive a capped amount for each beneficiary. The proposal calls for this capped payment to grow at the rate of medical CPI plus one percentage point. It's not clear that this adjustment factor saves a lot of money. If not, it then doesn't do much to fill the budget hole (running into math problem one).

The House Medicaid proposal differs significantly from another leaked proposal, this one developed by a number of Republican governors. In particular, the governors do not want to be forced to assume increased risk for the cost of care for beneficiaries who are jointly eligible for Medicare and Medicaid. (The "dual eligibles" account for over one-third of all Medicaid spending.) At the same time, at least some Republican governors seem perfectly comfortable with substantial Medicaid funding cuts as long as they have increased freedom to cut people off of Medicaid and reduce benefits for those who remain. Of course, this would just shift costs onto providers and beneficiaries. In essence, perhaps in an effort to keep senior citizens, people with disabilities and the providers who serve them on the sidelines, the governors' plan boils down to massive eligibility and benefit cuts for non-disabled adults and children.

Especially if the votes aren't there for tackling the tax-exclusion, then the Medicaid cuts would have to be deeper – much deeper – than what is laid out in either of the leaked draft proposals.  And benefits would likely be even skimpier both for Medicaid beneficiaries and in the private market. An analysis of the replacement plan based on documents released by Speaker Ryan suggests that millions would lose coverage. Such draconian cuts in health coverage would spark even more public outcry and could erode support in both the House and Senate, even though one House leader called a decline in coverage "a good thing" (again, see math problems two and three, above).

All in all, once the "original sin" of repealing the ACA taxes is committed, solving all three "math problems" – i.e., finding a way to make the budget numbers work while keeping a majority of support lined up in both the House and the Senate and not enraging the voters – adds up to a monstrous headache for Speaker Ryan and Leader McConnell. (Sad!)  Perhaps that's why former House Speaker Boehner predicts that the Republican effort to repeal most of the ACA will ultimately fail.

Let's hope he is right.

This is the third 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.

While one of the primary goals of the Affordable Care Act (ACA) is to expand access to quality, affordable health coverage for all, young adults (ages 18-34) have benefitted more than many! ACA policies such as allowing children to stay on their parents’ plan, expanding Medicaid eligibility and offering tax credits to individuals signing up for individual marketplace coverage have all contributed to a remarkable decline in the rate of uninsured young adults. Overall, 6.1 million young people have gained coverage since the ACA’s passage, including 2.3 million who remained on their parents’ plan and 3.8 million who gained coverage through Medicaid or the marketplace.

However, the election of Donald Trump as president has left the ACA in peril. The president-elect has reaffirmed his campaign pledge to repeal the ACA and the Republican majority in Congress has put it at the forefront of their policy agenda. Although the new Republican leadership has yet to coalesce around a plan to replace the Affordable Care Act, what has thus far been proposed would likely cause millions of young adults to lose access to the affordable, continuous and robust coverage they’ve gained from the ACA.

Young Adults Together

Image Attribution: Newscast Online

What young adults stand to lose:

  • Help purchasing affordable coverage: Currently, the ACA provides tax credits to individuals based on their income to help pay for premiums, with lower-income individuals receiving more assistance than higher-earners. In contrast, the proposed replacement plans would offer flat-dollar amount tax credits based on age while ignoring other factors such as health and income level. Under this plan, young adults would receive the smallest amount of financial assistance, disadvantaging young adults with chronic health problems or who are low-income. As Sarah Kliff of wrote, “This means that Bill Gates would qualify for the largest tax credit simply because he is 61 years old…[c]onversely, a 23-year-old with little income and health issues gets minimal help...despite the fact that he may need support much more than Gates does.”
  • Loss of flexibility for changing circumstances: Compared to other groups, young adults have been more likely to be uninsured and twice as likely to lose coverage during the year. Activities that cause a loss of coverage, like graduating from college, aging out of parents’ coverage or leaving a job are all more likely to be experienced by young adults. Similarly, young adults are more likely to experience a life event, such as having a baby or getting married, that might necessitate getting coverage. The ACA sought to prevent these individuals from slipping through the cracks of coverage by providing special enrollment periods (SEPs), 60-day windows outside of the annual open enrollment period for individuals experiencing these types of life events to enroll in coverage. Unfortunately, Health and Human Services Secretary nominee Tom Price’s proposed replacement plan would substantially penalize anyone experiencing an insurance gap: insurers would be able to charge enrollees who experience a lapse in coverage up to 150 percent more than the standard premium price, and enrollees would be required to pay this increased amount for 18 months before they could pay the standard amount.
  • Ability to enroll in expanded Medicaid: More than 15 million individuals have enrolled in Medicaid since the expansion began in 2014, including many low-income young adults. Unfortunately, many of the proposed replacement plans would eliminate the expanded Medicaid provided by the ACA, meaning that young adults who have taken advantage of this coverage would lose their health care. Prior to the ACA, more than half (52 percent) of uninsured young adults were in families with incomes under 133 percent of the federal poverty level (FPL). The decision of 32 states (including D.C.) to expand their Medicaid program represented one of the largest opportunities for the low-income, young adult population to gain coverage.

The results of the 2016 election have created new threats to the ability of young adults to access quality, affordable health care. Together, we must work to protect the reforms to private health insurance and Medicaid that have allowed young adults to access care. To help protect coverage gains for young adults in the fight ahead, advocates should continue to highlight the stories of young adults who accessed health care through their parents’ health plans, on the Marketplace or due to expanded Medicaid. It is important that your congressional delegation and the state stakeholders who influence them understand the role the ACA has played in ensuring coverage and security for this population.  

It is often said that the first casualty of war is the truth. In the coming war on health security for the American people, one question is whether Donald Trump was sincere when he said he would not cut Medicare, a claim he made repeatedly throughout the campaign. Unfortunately, his selection of Tom Price as head of HHS raises a bright red flag as to whether Medicare is truly safe. 

Price is on record not only supporting Medicare vouchers but also for allowing doctors to balance bill Medicare patients - as if people in this country didn't already have big enough problems with out-of-pocket medical bills. Based on his history, it is hard not to believe that older Americans and people with disabilities will be right up there with low-income people and people with pre-existing conditions at the head of the line to receive a cut in their health care benefits from the president and congressional Republicans.

And while we’re at it, I wouldn’t take too much comfort from stories suggesting that Senate Republicans are cool to a Medicare voucher or premiums support plan (there is no effective difference between the two, it is just a matter of whether the fixed dollar subsidy goes to the beneficiary or directly to the insurer). It's the timing of the attack, not its substance that seems to concern them most.

Meanwhile, at least some Congressional Republicans are realizing that calling for a repeal that has no chance of actually happening is a much easier exercise than actually crafting a workable alternative. Perhaps it has something to do with the fact that - despite continued division over ACA - the public is deeply skeptical of any moves to repeal it without having some clarity on the alternative. Only about one in four voters support ACA repeal, fewer than the 30 percent who want to expand the law. Roughly equal numbers support implementing the law as is and scaling it back. Even those who favor repeal want to see the alternative first.

Voters are right to be concerned. The lengthy time gap that Republican leaders are envisioning between repeal and replace would be a "slow motion disaster" for health insurance. Moreover, deep divisions over what direction to move in underscore the possibility that the party could be unable to come to any agreement on a new plan (just as they haven't for the past six years). The Senate Republican Policy Committee unveiled their plan to begin repealing what they call "the most harmful provisions of the ACA." Apparently tax credits and Medicaid expansion that make health insurance affordable for 22 million people qualify as "harmful." That’s probably a surprise to the people who are getting those benefits.

How the voters thought about health care

The election is over and Donald Trump, to the surprise of most people (including, apparently, the Trump campaign team) will be the next president of the United States. Although this will have profound consequences for health policy, it does not appear that health care issues were a major factor in determining the outcome.

Certainly, health reform never became the political plus that proponents hoped it would be, but neither was it the albatross that critics claim it was. Opinions about the health care law have remained essentially stable and dominated by party identity since the Affordable Care Act (ACA) was passed. In addition, health care remained a second-tier issue throughout the campaign.

According to analysis by Robert Blendon at the T. H. Chan Harvard School of Public Health, a single core question – whether you believe the federal government should play a significant role in ensuring that people have access to coverage – was strongly associated with both your attitude toward the ACA and toward the presidential candidates. People remain largely uninformed about the details of the ACA. Their attitudes are driven by values, not the specific provisions of the law (many of which remain broadly popular).

One interesting correlation between health and voting was discovered by staff at The Economist. Counties with high rates of obesity, diabetes and heavy drinking and low rates of physical activity went heavily for Donald Trump. These voters, hit hard by deindustrialization and not benefiting from a rebounding economy, made up a small percentage of Trump voters. But they may have provided him with his margin of victory in key battleground states.

Turning from the electorate to policy that may flow from the outcome, the Affordable Care Act is a law that has had nine lives. But in the wake of Trump's victory it is now threatened like never before. Truly, the fate of the ACA per se is neither here nor there. The urgent question that confronts us now is how to preserve the coverage gains and financial protections that millions of people now enjoy. Twenty-two million people could lose their coverage outright if the ACA is repealed, but that is just the tip of the iceberg.

The ACA provides important benefits to millions of people who never even glanced at, such as protections against pre-existing condition exclusions and charging sick people more for their coverage, limits on rates charged to older adults, the bans on lifetime benefit caps and charging women more than men, and better access to preventive health services. All of these protections are at risk if the ACA is unraveled.

And the damage doesn't stop there. House Republicans have put forward the outline of a plan that would undermine coverage for millions of children, seniors and people with disabilities who depend on Medicaid. They have also proposed reducing benefits and increasing costs for Medicare beneficiaries.


Would you buy a used car from these men (sight unseen)?

For six years, Republicans have been talking about repeal and replace, but they have yet to coalesce around a replacement plan. Now Republican leaders in the House and Senate are pursuing a strategy of repeal now and replace later. They are proposing to light a fuse by repealing essential components of the ACA but delaying the effective date. Essentially, they’re saying, "Trust us we'll come up with something good to replace it before the bomb goes off."

But there is nothing in the past six years that should give people any confidence that Republicans can pull it off. A large cohort of Republican voters (and presumably their representatives) would be content to repeal the ACA and replace it with nothing. In addition, the overall intent of the Ryan blueprint, much of which is also reflected in Trump's policy agenda, seems to be to use health care programs as a piggybank to pay for (wait for it) tax cuts for the wealthy and increased military spending.

There is also a great likelihood that the "bomb" will go off early. Even if there is a delay in cutting funding for premium tax credits, insurers are less likely to participate. And the more uncertainty there is about the shape of any future system, the less likely healthy people are to sign up for coverage. This will drive premiums up and enrollment down.


Meet the real Donald Trump

President-elect Trump's position on these issues is unclear. During the campaign, Trump said a lot about protecting Medicare (and Medicaid). While he was clear about repealing the ACA, he often spoke about making sure people had better, more affordable coverage. Cynics might think that he was about as sincere as a snake oil salesman promising miracle cures. Certainly his recent embrace of "Medicaid flexibility" and Medicare modernization," both often code words for program cuts, is cause for concern. An early tip off as to his true intent will come as he positions himself relative to Congressional plans to repeal without having a replacement plan ready.

Once funding for premium tax credits and Medicaid expansion is repealed, it is no longer available to help finance a replacement plan. This means that whatever comes next will be much stingier than would be the case were that funding still available. Reduced funding will not only undermine coverage for the newly insured, it will also financially destabilize many providers and result in a large cost-shift to state government.

However, it appears that the incoming Trump administration is on board with the Congressional scheme making his promises to protect Medicare and Medicaid and replace the ACA with "something terrific" much harder to realize. Because separating repeal from replace would be so damaging, it is important to mobilize now against this approach. Republican leaders are hoping to hold a repeal vote in January in order to present a repeal bill on or near Trump's first day in office. Much of the health care community, including Community Catalyst, is now focused on opposing this plan to repeal the ACA without a replacement.


We the People

Donald Trump was elected by a minority of the electorate. Most people do not want to see the ACA repealed. They don't want to go back to the days when insurance companies could discriminate against people based on their health status. They don't want to cut health benefits for children, seniors, or people with disabilities. The challenge now is to ensure that the views of the minority do not undermine hard-won health security for millions of Americans.

With the musical “Hamilton” putting the American Revolution into popular consciousness, a couple of random bits of Revolutionary War trivia have recently popped into my mind. As the reality of Trump's upset victory sank in, I recalled the song that the British played as they surrendered to Washington at Yorktown—“The World Turned Upside Down.” But now, as the shock has worn off, I recall instead the words of John Paul Jones (the Naval hero, not the Led Zeppelin bass player): “I (we) have not yet begun to fight.”

Coverage success for children did not happen overnight and is not static. As we enter the next open enrollment period, we are reminded that coverage and maintaining coverage is ongoing and requires year-round support. This is especially true for children whose needs change as they grow and their opportunity for coverage changes with them.

Rate of Uninsured Children | Below 5 %

Photo Copyright: Georgetown University Health Policy Institute, Center for Children and Families

Yesterday, Georgetown University Health Policy Institute’s Center for Children and Families celebrated health coverage gains for children around the country. The results of their report warrant celebration: 95% of children now have health care coverage with approximately 1.7 million children gaining coverage between 2013 and 2015. Since 2008, the number of uninsured children has been cut almost in half, reflecting the same period of time when the Children’s Health Insurance Program Reauthorization Act (CHIPRA) and the Affordable Care Act were enacted. This milestone is a direct reflection of national, state, and local advocacy working together to remove barriers for children to lead healthy, productive lives by providing them with the health coverage they need to succeed.

For New England, the results were particularly stunning. Thirty states now have rates of uninsured children lower than the national average, including all of New England except for Maine. Vermont and Massachusetts top the list of states with the lowest rates of uninsured children in 2015, respectively. The trends in Maine reflect the Governor Paul LePage’s broad opposition to the Affordable Care Act and Medicaid: He continually supports cuts in Medicaid – most notably, dropping 28,500 parents from Medicaid in 2013 and 2014 prior to ACA rollout.

For the states with coverage improvement for children, parent uninsured rates have also declined significantly since enactment of the ACA. This data reflects that extending parents coverage results in more children obtaining coverage, as well. And research tells us that when parents are covered, children are more likely to have coverage

Children need continued access to health care coverage in order to perform well in school, stay on track developmentally, remain healthy, and get treatment for medical needs. Research shows that children with Medicaid coverage are less likely to drop out of high school and more likely to graduate from college – covered children grow up to be healthier and more financially secure adults. It is clear that investing in children’s health is an investment in our communities’ economic growth and future.

There is still much work to be done. Half of all remaining uninsured children in the United States live in the South, and a disproportionate number of uninsured are older children and Hispanic children. With these gains and challenges, there still remains a risk to children without continued strengthening of the Affordable Care Act, CHIP and Medicaid. Coverage for children and families results in greater access to care and positive health outcomes, reinforcing the need for advocacy to call on continued efforts to close the coverage gap.

In 2003 and 2004, I traveled to communities in Texas, Mississippi, Illinois, Idaho and Massachusetts to meet individuals and families scraping by without health insurance. They told me stories of jobs that did not provide health insurance, untreated health problems that led to lay-offs, declining employability, medical debt, evictions and loss of homes, and sometimes even death. The results of that project were published in 2005 as “Uninsured in America: Life and Death in the Land of Opportunity” by University of California Press.

In 2015, I returned to these communities to learn how the people I had originally interviewed were faring in the wake of the Affordable Care Act as well as the broad social and economic changes of the past decade. Altogether, I looked for 145 people and was able to re-interview 82. While some of the people were now insured and far healthier than they had been a decade earlier (see “Faces of the Newly Insured”), at least 10 people were dead and 36 people had disappeared without a trace from the homes and communities in which they’d been living when I first met them.

It took weeks to get a glimpse of the lives of those less visible Americans who generally manage to rent housing of some sort for periods of time but teeter on a financial edge that keeps them moving from place to place – with all of the negative implications that residential instability have for health and health care.

Shanice’s Story

I first met Shanice in 2003 at one of the larger Black churches in Decatur. She was happy to share her story with me:

“When I was 18 I worked a job, it was right after coming out of high school. No insurance and they said I wasn’t eligible for Medicaid. My doctor said I needed to get my tonsils taken out cause they were so swollen it was almost causing me not to be able to breathe… And so I had to go on like a payment plan with the doctor… The whole surgery, the surgeon, the day at the hospital and then I had a setback and had to go back into the hospital cost $15,000. During the following year collection agencies called day and night. Said that I would be going to jail if I didn’t pay them.” At age 20, Shanice filed for bankruptcy.

A few years later Shanice gave birth to her daughter. By this time, Shanice was working for a storefront loan company that provided health insurance for her, but not for her daughter (she would have had to pay a premium she could not afford on her salary).

Before long, their statuses reversed. When Illinois expanded Medicaid for children (Kid Care) her daughter became covered. Shanice, having left her job to go back to school, became uninsured. She was well aware of the risk she was taking but was determined to build a better future for herself and her daughter. “It wasn’t just me living this carefree, don’t-worry-about- tomorrow life. Now I have someone that was dependent on me so I had to make decisions for the future.” Shanice also began to eat healthier meals and lost over one hundred pounds.

In 2003, I described Shanice in my notes as “a young woman on the way up.” She had just completed cosmetology school, was working part-time at her church, and was looking for her first professional job.


In 2004, I spoke with Shanice again. With a sense of resignation, she told me that medical and credit card debt had piled up and she was preparing to declare bankruptcy a second time.


In 2015, I returned to the address at which Shanice was living when I initially met her. She had moved on and none of the current neighbors recognized her name. I continued on, checking out another half dozen addresses I found for her on various search engines. Stopping by her church, I was told, “Shanice is no longer a member of this church. She’s moved.” No one at the church knew where.


In early 2016, I made another visit to Decatur. A member of Shanice’s (former) church had heard she was working at an office. I called the office and was told Shanice had been hired there as a "temp" and was no longer working there. Welcome to the new American economy, Shanice.

Health and Housing

I have no doubt that if Shanice had turned 18 in the era of the Affordable Care Act, her experiences would have been quite different. She either would have been able to stay on her parents’ health insurance or she would have been eligible for Medicaid (Illinois has expanded Medicaid under the ACA). Not only would she have avoided medical debt and ensuing bankruptcy, but she may even have been able to access treatment that could have averted the expensive surgery to begin with.

The ACA would not, however, have saved her from the consequences of housing challenges.

At a community health center in Decatur, nurse administrators Karen Schneller and Tanya Andricks explain that it is impossible to provide follow-up care for patients who can’t be reached – whose phones are turned off and mail is returned “addressee unknown.” Even if they are able to access care in the next place they land, people like Shanice find different facilities and providers prefer different medication and treatment protocols. This results in a range of problems resulting from stopping and starting diagnostic and medication regimes with each move.

In my quest to re-interview Shanice and other uninsured men and women whom I’d met back in 2003, I visited abandoned housing projects, meth houses, developments abutting unfenced dumps, squatters living in shacks without floors, and a building in which a pack of feral-looking dogs roamed the hallway.

I do not know if Shanice and her daughter have been fortunate enough to avoid these sorts of grossly insalubrious living quarters. I do, however, know that they are unlikely to have benefited from the health-enhancing social capital that comes with living in a stable community or from the health-preserving care that comes with having a stable medical home.

Susan Sered, PhD, author of “Can't Catch a Break: Gender, Jail, and the Limits of Personal Responsibility,” is professor of Sociology at Suffolk University in Boston.

Second in a series addressing implicit bias in health care

In the aftermath of the unsettling tragedy that unfolded in Orlando last month, we are again reminded about the issue of discrimination and the challenges that lie ahead on multiple fronts. Discrimination is as pervasive in health care as it is other aspects of society, and ultimately undermines the values of justice and equality that we as a country depend on and fight so hard to protect. LGBTQ communities, in particular, continue to face alarming disparities in health that reflect the unfortunate impact of bigotry and prejudice. For example, research found 42 percent of transgender adults reported verbal harassment, physical assault or explicit denial of equal treatment in a hospital or doctor’s office.

Last month, the Department of Health and Human Services (HHS) took a pivotal step forward in prohibiting discrimination in health coverage by releasing a final rule implemented under Section 1557 of the Affordable Care Act. Section 1557 provisions are undoubtedly a victory for all Americans as they prohibit discrimination on the basis of an individual’s race, color, national origin, age, disability or sex for all health programs or activities receiving financial assistance through HHS. The final rule is especially critical for LGBTQ people because banning sex discrimination includes protections on the basis of gender identity and sex stereotypes, which  has the increased potential to reduce health disparities. Still, there are concerns about how some providers are held accountable for service delivery and health outcomes if they are financially exempt.

There is also an additional opportunity to look beyond the policy scope referenced in Section 1557 to address less visible, but equally serious forms of discrimination that still influence policies and practices. As we highlighted in our April blog addressing implicit bias in health care, several studies show that bias among health care providers is one major factor contributing to disparities in access to high quality care. The disparities evident in research may reflect that traditional training current health care providers receive does not adequately address the health needs of historically marginalized communities. New approaches are therefore needed to integrate practices, standards, and policies for how health care services are delivered in hopes of producing more equitable outcomes.

Last year, the University of Louisville took an initiative to improve the essential health care needs of LGBTQ populations by piloting a medical school curriculum called eQuality Project. The program embeds formal implicit bias training directly into the curriculum, which includes a requirement that first year medical students, complete Implicit Association Tests (IATs). Students participating in the program must complete three IATs before beginning the curriculum as a baseline and are encouraged to complete additional post-tests. Post-test results are then matched to baseline results to determine differences. The rationale for exploring bias at early stages in the curriculum is that doing so will establish a framework of accountability for students in their approach to the work both within the program and beyond.

While IATs are the core of the curriculum at the University of Louisville, health systems like Kaiser Permanente place a larger emphasis on identifying opportunities for physicians to directly engage with vulnerable populations outside of the exam room. Dr. Ted Eytan, who works with Kaiser Permanente as a longtime advocate for equal benefits to the transgender population, maintains a collection of resources that helps break down hidden power dynamics in patient and provider interactions. He acknowledges that biases may not be erased but can be changed through exposure by building awareness and sensitivity about the unique challenges of patients who physicians work with. Through his work with Kaiser Permanente, Dr. Eytan also encourages auditing the day to day environment as a provider, and reports how simply taking a few minutes to ask questions not only humanizes a patient, but also changes a dynamic where bias may otherwise enter. 

The University of Louisville and Kaiser Permanente are leading efforts to disrupt existing patterns in health disparities by encouraging health care providers to understand health factors that are strongly influenced by different, often unequal, interactions that individuals have with the larger society. We must strive to intentionally promote a culture of knowledge where social variations are not treated as invisible, illegitimate, or negative, but instead as opportunities to learn and grow. The provisions under Section 1557 are an important step in the right direction, and also present a challenging but critical opportunity for us to look beyond the policy scope to practice. We will need to move forward on both fronts by changing discriminatory policies in the provision of care and also encouraging, equipping and supporting health care providers with the knowledge and resources needed to tackle discrimination and bias as barriers to achieving health equity.

Stay tuned for the third and final blog of this series, which will focus on examining policy recommendations that are needed at different levels of the healthcare system.

After six-plus years of rhetoric and sixty-some repeal votes, the House Republican caucus finally produced a document they refer to as a plan to replace the Affordable Care Act. (To call the plan disappointing would be an understatement. Despite my low expectations, the document the Republican working group produced was even worse than I thought it would be.)

It is a paltry effort. Six of the document's 37 pages are essentially devoid of content. Much of the remainder is taken up with political bombast full of misleading and flat out untrue statements. The actual policy proposals it does contain, when it pauses for breath from excoriating the ACA, are a warmed over rehash of the same harmful, unworkable ideas various Republican lawmakers have been pushing for years with nearly all of the critical details missing. Although the lack of detail makes any precise comparison to the ACA impossible, it is safe to say that if adopted, the proposals released this week would cause millions of people to lose their health insurance, and increase health care costs for millions more.

It's not worth the time to read, let alone to write a correction of every misstatement and deconstruction of every bad idea, but here are some of the "highlights."

Undermines critical insurance reforms while shifting costs to lower-income people and benefits to the affluent

A few of the ACA insurance reforms would remain, such as allowing young adults to stay on their parents' plan and no lifetime benefit cap. However, most reforms would likely be swept away, such as access to preventive services with no cost sharing. There would be no guaranteed minimum benefit package, and tax credits would not adjust with income, so lower-income people would be less able to afford coverage. Many would drop out of the insurance pool since the individual mandate would also be repealed. Credits would not adjust to keep pace with the rising cost of insurance, so every year fewer and fewer people would be able to afford coverage.

The Republican "plan" would also make shopping for coverage much more difficult. There would be no plan standardization. Competing "private exchanges" would be allowed, each of which might have a different set of insurers and benefit designs. Making "apples – to - apples" comparisons would become almost impossible.

At the same time tax credits for low-income people are wiped out, Republican lawmakers would double down on high deductible health plans and Health Savings Accounts (HSAs) by increasing the amounts that could be contributed to HSAs. This change primarily benefits those in higher tax brackets who also have the spare cash to put into their accounts.

Would cause millions to lose Medicaid coverage and increase financial barriers for those that remain. Children, in particular, could lose vital protections.

Apparently, the drafters couldn't decide between a Medicaid block grant and a Medicaid per capita cap, so they included both ideas and would let states decide. Either way, beneficiaries would lose. Federal contributions would not keep up with health care costs, and states could for the first time create enrollment caps or waiting lists to exclude otherwise eligible beneficiaries from coverage. Financial protections would be scaled back allowing states to impose higher premiums on beneficiaries that would force many to drop coverage. Those who remain could also get fewer services and pay more in cost sharing. If states chose a block grant instead of a per capita cap, beneficiaries would fare even worse, especially children, who would lose nearly all of the current legal protections that ensure low-income children have a comprehensive benefit package with no cost sharing.

With more and more costs shifted onto states, and with states having more freedom to shift costs onto beneficiaries or exclude currently eligible people altogether, there is little doubt that millions would be harmed.

Erodes benefits and increases costs for Medicare beneficiaries

Repeal of the ACA would immediately increase prescription drug costs for Medicare beneficiaries by eliminating the expansion of the Medicare drug benefit. Most beneficiaries (those who didn't go to the hospital in a given year) would also see higher out-of-pocket costs through a new deductible structure that would increase the amount they would have to pay for most services before Medicare kicked in. The Republican work group also proposes increasing the Medicare eligibility age, an idea that CBO has determined does not save much money for the federal government but does increase costs for employers and individuals.

But wait, there's more. Starting in 2024 Medicare beneficiaries would lose guaranteed access to a defined benefit package. Instead, they would be given a set amount of money they could put toward a plan. While the details are lacking, one thing that is clear from the document is the size of this payment would shrink over time relative to the cost of health care, leaving seniors and people with disabilities with ever skimpier coverage.

And now for the good news (sort of)

The ideas contained in this grab bag of horribles are wildly unpopular, and an attempt to enact them would provoke a huge backlash. Even in the event of a Trump election this doesn't represent where actual health policy would go, since under any conceivable scenario Republicans would not have enough votes to pass a bill like this. Moreover, not all of these changes could be made via budget reconciliation. That said, and despite all the missing detail, this compendium of "greatest hits" creates a chilling picture of where health care could be heading depending on what happens this November.

Last June, following the mass murder in Charleston, South Carolina, Anton Gunn, a South Carolinian and Community Catalyst board member, commented on Governor Nikki Haley’s (R-SC) change of heart about taking down the Confederate flag from the grounds of the South Carolina State House. Gunn asked at that time a vital question: “If you take the flag down tomorrow, what is going to substantively change in the lives of black people and people affected by inequality in South Carolina?” 

A similar question can be asked of Governor Rick Scott (R-FL) following the mass murder at a gay nightclub in Orlando, Florida -- the deadliest mass shooting by a single gunman in the United States. Scott laid flowers at a memorial in Orlando to the victims, who were predominantly Latino and members of the city’s LGBTQ community. While we can appreciate his gesture of sympathy, we need to ask him a similar question: What are you doing to substantively change the lives of lesbian, gay, bisexual and transgender people in Florida? What are you doing to substantively change the lives of Latino people in Florida? Despite the fact both these groups are at disproportionate risk of being uninsured, Scott – like Haley – opposes closing the coverage gap. As a result, nearly a million people are uninsured in Florida and many among them are LGBTQ and/or Latino. It is likely that some among the men and women seriously injured in the Orlando attack, and facing a long and difficult road of recovery and healing, are doing so without the benefit of insurance coverage that could have been available to them through enlightened state action.

Governor Scott is also a strong opponent of gay marriage and sensible legislative proposals to strengthen background checks and reduce the availability of assault weapons.

Given the long and painful history of discrimination against marginalized communities in our nation, the laying of flowers – like the lowering of an offensive flag – is not sufficient to satisfy the needs of people. For justice’s sake, we need to demand more. And that will require people to stand up to Haley and Scott and demand substantive change.

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