Posts About Health Equity

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

When Ronald Reagan framed unwed, poor mothers of color fraudulently relying on government assistance programs as “welfare queens” during his presidential campaign speeches in 1976, the image of the underserving poor took on a form of Black mothers whose lack was justified – lack of resources, lack of access and lack of equity. Now, as Black women are three to four times more likely to die from pregnancy-related causes than White women, it’s time to drop the deserving versus undeserving poor narrative and work to repair the damage of structural racism meant to deny communities of women equitable rights to have healthy pregnancies and families when they choose to.

Storytelling in health advocacy is often a useful approach to give stakeholders, policy makers and other advocates an image of a policy initiative’s impact. These narratives apply a much-needed human aspect to what otherwise could be lost in data and numbers by sharing a human experience and generating social sympathy. But what happens when narratives turn negative, relying on racism, sexism and classism to paint a picture of the deserving and underserving of health resources and social services – especially of black women who are now at most risk for poor maternal health outcomes?

Currently, Black maternal mortality is not just a problem among those with a low socioeconomic status. In fact, the birth outcomes disparities between Black women and White women show similar poor outcomes across all income and education levels, suggesting a direct link to racism further supported by racist narratives.  Social determinants of health are “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. Through policies and programs within the social determinants of health, racist narratives create barriers and can impact how women access health coverage, quality care, employment and other resources to achieve optimal health. Using theories like Critical Race Theory  to analyze how racist narratives permeate into policy and programs can help shift view and ultimately outcomes. By rejecting a tradition of meritocracy, the false picture that everyone who works hard can attain wealth, power and privilege is denied and instead we can recognize the impact that systemic inequities have on the marginalization of people of color.

Last month, the Black Mamas Matter Alliance (BMMA) held their first briefing on Capitol Hill to highlight their work and build a supporter base around the alarming rates of black maternal mortality in the United States. Led by Black women, including Community Catalyst board member Dr. Joia Crear-Perry, BMMA is a cross-sectoral alliance that centers Black mamas to advocate, drive research, build power and shift culture for Black maternal health, rights and justice. Through their work, BMMA purports that all women have the right to safe and respectful health care that supports healthy pregnancies and births. These rights mean that before, during and after pregnancy, every woman needs access to quality health services and information, to the social and economic resources that will help her be as healthy as she can.

Critical to black maternal health is our current advocacy campaign to save Medicaid and the Affordable Care Act for children and families. Now is the time when we have to eliminate the racist narrative of the “welfare queen.” Our stories must center around addressing racial discrimination and structural racism by recognizing it. By shedding light on the harmful outcomes of health inequities, we can share multiple narratives. We must also continue to frame our message using a two generational approach meaning that a family’s access to health care cannot be siloed. Healthy parents – mothers and fathers – are able to care for their children, helping ensure that they thrive and become healthy adults. Specifically, when mothers die, it breaks apart families and can lead to negative health consequences for their children. We must trust Black women with the decisions and resources that empower them and their families. We must trust black women to tell their own dynamic stories and shape the narratives that reflect their realities. In her TED Talk, novelist Chimamanda Ngozi Adichie shared, “The problem with stereotypes is …that they are incomplete. They make one story become the only story.”

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

The Better Care Reconciliation Act (BCRA) would result in 22 million people losing their health care coverage over the next decade, cause long-term damage to the Medicaid program and raise health care costs to extremely unaffordable levels for consumers. Millions of low-income people of color, especially those with chronic health conditions, would be among the hardest hit. A recent analysis conducted by the Urban Institute estimates that by 2022 roughly 21 percent of those who would become uninsured because of BCRA are Latinos, and 12 percent are Black. This bill would reverse racial health equity gains made under the Affordable Care Act (ACA) and strike a blow against signature victories for racial equality in America.

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

According to the Kaiser Family Foundation, more than one in five adults of color and nearly six in ten children of color are currently enrolled in Medicaid. Medicaid represents an important source of insurance coverage for low-income people of color who are more likely than whites to work in low-wage jobs that provide limited access to employer-sponsored insurance. The program is a vital tool for states to respond to fluctuations in unemployment, public health crises and changes in population growth many of which disproportionately affect people of color. Yet, according to the Congressional Budget Office, the BCRA would cut as much as 26 percent of Medicaid funding ($772 billion) over the next decade, which would hamstring state programs and budgets. Specifically,

  • The BCRA would effectively end Medicaid expansion, putting at least 15 million low-income people at risk of becoming uninsured and losing access to the care they need. For people of color, eliminating Medicaid expansion would leave as many as 1.5 million African Americans and 3.3 million women of color without health insurance or enrolled in extremely expensive private options with deductibles as high as half of their annual income.
  • The BCRA would permanently convert Medicaid to a per capita cap funding system, which would not keep up with the underlying costs of the program. Because of massive losses in Medicaid funding, states would be forced to cuts costs by eliminating essential programs and services people of color are dependent upon. Many rural hospitals would be forced to close down. Particularly in southern states with centuries’ worth of social and structural inequalities, African Americans and Latinos who have already experienced worse health outcomes would have to travel longer distances for essential and preventive care or die from emergency conditions (like accidents or heart attack).

Allowing states to drop the Essential Health Benefits (EHB) for private insurance, leaving millions of people with pre-existing conditions without essential coverage 

On average, people of color experience shorter life spans, higher infant mortality rates and higher prevalence of many chronic conditions compared to whites. This bill would take away access to critical care services (including prenatal and maternity care, chronic disease management and treatment for mental health and substance use disorders) from people of color who face serious physical, mental and behavioral health problems.

Eliminating the Prevention and Public Health Fund would cut supports to low-income and vulnerable communities

The BCRA would end the appropriations for the Prevention and Public Health Fund, which would directly affect everyday Americans and their families living in low-income and underserved communities. Facing massive cuts in Medicaid and prevention funds, states would be unable to prevent the onset or spread of infectious diseases (such as measles, zika and ebola) and redress long-standing inequities in health and safety by investing in communities with greatest needs.

The BCRA is dangerous for millions of low-income and vulnerable Americans. The combined effects of the BCRA have devastating and long-term impacts on the health and economic security of communities of color. We need to keep up our pressure on Republican Senators and plainly call out the damaging impacts this bill would have on their constituents.

By now, you’ve already seen the key takeaways from the Congressional Budget Office (CBO) score of the Senate repeal bill. But what you might not know is that the CBO score hides the most devastating of the Senate bill’s effects. Indeed, the CBO score only shows the tip of the blade that will continue to slash into Medicaid for decades to come.

According to the CBO’s analysis released yesterday, over the period of 2017-2026, the Senate’s repeal bill would:

  • Cause 22 million people to lose their health care coverage by 2026
  • Cut $772 billion from Medicaid – slashing its funding by 26 percent, and blowing a hole in state budgets which would likely lead states to cut essential programs and services for seniors, people with disabilities and children.
  • Slash the subsidies available to low- and moderate-income families by $408 billion, and leave families exposed to far higher out-of-pocket costs.
  • Eliminate the Medicaid expansion that covered millions and replace it with private coverage that the CBO says would become so expensive they would not be able to afford it. For example, a person earning $11,400 would face a deductible of more than half their annual income.
  • Lead close to half the population to lose access to critical services, such as maternity care and treatment for substance use disorders
  • All this, just to finance tax cuts for the wealthy.

But the CBO score hides the worst of the Medicaid cuts, because its projections stop in 2026 - just as the Medicaid cuts begin to sink even deeper.

Starting in 2020, the Senate bill would cap the federal contribution to states’ Medicaid programs and would force it to grow at a rate that is slower than per capita Medicaid costs (the Consumer Price Index – Medical (CPI-M) inflator for most enrollees and CPI-M plus 1 percentage point for disabled adults or age 65 or older.) Since CBO projects per capita costs of non-disabled children and adults to rise at 4.9% - but CPI-M will only be 3.7% – this change alone would result in significant reductions in states’ Medicaid funds.

But starting in 2025 – at the very end of the CBO score’s time period – the Senate bill would make far deeper cuts in Medicaid by dramatically slowing the growth of the per capita caps for all enrollees to Consumer Price Index for all urban consumers (CPI-U). The CBO projects CPI-U to grow only at 2.4% annually over this time period, while costs of non-disabled children and adults will rise at more than twice that rate.

This shift would push dramatically more costs onto states, but conveniently (for the Senate GOP leadership) it is barely captured at the tail end of the CBO’s 10-year score window. And it exemplifies how converting Medicaid into a capped funding program merely creates a dial that Congress could ratchet up for additional savings every time it needs to pay for another priority. (We already saw this in the Trump budget where they sought to add hundreds of billions of dollars in cuts on top of those that were in the House's version of ACA repeal.)

This massive cost-shift to states would only grow year after year. It would force states to eliminate life-saving services for children with special health care needs. It would deprive people living with disabilities of the services they need to live independently and it would shift new costs onto family budgets as they struggle to find ways to balance the health and long-term care needs of aging parents against other demands.

After reviewing the Senate repeal bill, the National Association of Medicaid Directors concluded, "No amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill." So as scary as the CBO score is, remember this: the worst would be yet to come.

Even close readers of the news can be forgiven for not understanding how perilously close the Senate is to not only ripping coverage away from millions of people, but also cutting Medicaid funding for children, seniors and people with disabilities and putting a vice around the program. After all, there continue to be multiple conflicting reports relating to the content, timing and degree of agreement among Republican senators. So, without further ado, your handy guide to what we know and don't know about where things stand in the Senate.

More like the House bill than not

Despite all the denials and claims that they are starting over, the House bill will provide the basic architecture of what the Senate does. It is not the case that the Senate will bring the House bill to the floor and then replace it with a substitute that looks much different. The key elements of the House bill – eliminating the Medicaid expansion, capping federal Medicaid funds to states, slashing tax credits and cost-sharing assistance in a way that particularly harms lower-income and older people, undermining insurance market protections for people with preexisting conditions, and big tax cuts for the rich and for insurance companies and the drug industry – will all likely be retained in the Senate proposal.

Less opposition than you might think

There is more support in the GOP Senate caucus for this "basket of deplorables" than people may realize based on senators’ public statements. In particular, it would be a mistake to conclude that members who have expressed skepticism that the Senate will pass a bill will themselves ultimately be a “no” vote. Everyone is still leaving themselves with a lot of wiggle room, and many of the most vocal Senate critics of the House proposal have begun making positive noises about the Senate bill, even though it will be very similar (Senator Cassidy, a case in point).

Sooner rather than later

The issue is coming to a head sooner rather than later – McConnell wants to get off of health care and move on to other matters like reforming the tax code. We are expecting a Senate vote before the July recess begins on June 30, though it is not impossible that it could slip until immediately after the recess. That doesn't mean the Senate Majority Leader will just throw a bill out there and figure “if it fails, it fails.” The public comments following the Republican caucus last week suggest that he is making headway toward getting the 50 votes he needs.

Don't expect to see the bill in advance

The exact contours of the Senate proposal will be kept from the public (and the members) until the very last minute. While the situation is serious, some important decisions and significant fault lines remain, including:

  • Medicaid: With respect to Medicaid, the timing of the phaseout of the expansion remains uncertain. A number of senators are on record in support of a seven-year phaseout of enhanced federal match. While the disastrous end results would be the same, there appears to be a sense among the "moderates" that a slower phaseout provides better optics and ideally – from their point of view – delays the worst consequences of the bill until after their next reelection bid, whether that falls in 2018, 2020 or 2022.
  • Per Capita Cap Growth Rate and Base Year: There has been an ongoing debate between senators who want to keep or improve on the growth rate in the House bill and those who want to cut Medicaid spending even more than the $839 billion in AHCA. There have been rumors of a trade between a lower growth rate and a longer phaseout of the expansion, but at this point those remain rumors. Meanwhile, both the growth rate and the base year of the cap have emerged as potential flash points. Some senators from low-spending states have voiced concerns about being unfairly locked into lower federal reimbursement rates in perpetuity.
  • Tax Credits: The Senate will try to add some money back to the House proposal to soften the blow on lower-income and older adults, but they are unlikely to have enough money to prevent a massive drop off in insurance coverage. The question is whether that will deter any senators from voting for the bill and whether we will even know the CBO estimate of the effect on coverage before the Senate votes.
  • Tax Cuts: Expect the Senate proposal to mirror the House but with delayed effective dates to help pay for the slower phaseout of the Medicaid expansion and for adding money to the tax credits.
  • Consumer Protections: The provision allowing states to let insurers charge people more if they are sick or "high risk" will likely fall out, but state waivers of Essential Health Benefits at this point appear likely to stay in. With dramatically lower premium support, states will be under pressure to cut down the benefit package whether they want to or not. The result will be a big spike in out-of-pocket costs, particularly for people with serious and expensive health conditions.

While the Senate is trying to speed toward the floor, some process challenges remain that have not been fully worked through. Three are worth keeping an eye on:

1. Cost Sharing and the Indian Health Service

Democrats are arguing that the provision of the law that eliminates cost-sharing assistance touches on the jurisdiction of the Indian Affairs Committee. Since that committee did not receive reconciliation instructions, sending the bill over to the Senate as-is could remove the protection of the reconciliation process and subject the bill to a 60-vote requirement, under which it would certainly fail. To avoid this, the House would have to amend the bill before it is formally transmitted to the Senate.

2. Allocation of Savings

In order to comply with the reconciliation instructions, which are what enable the bill to move forward with a simple majority, both the HELP and Finance committees must identify at least $1 billion in savings. Senate Budget Committee Chair Enzi has asserted both that the bill meets that test and that he is the arbiter of whether it does or doesn't. Ranking minority member Sanders is arguing that the bill fails the test and that the Parliamentarian must make a ruling.

3. Abortion

The House bill prohibits tax credits from being used for plans that cover abortion. This could run afoul of the Byrd rule, which requires provisions in a reconciliation bill to have a more-than-incidental effect on the budget. If the language is stricken, anti-choice legislators in either the Senate or House could withdraw their support from the tax-credit provisions entirely, which could sink the bill.

Even as more moderate members have indicated that they are encouraged, the most reactionary members are starting to voice concern and displeasure. Since McConnell can’t afford to lose three votes in the Senate, opposition from Senators Paul, Lee and Cruz, among others, could sink the bill.

With all of the uncertainty swirling around, McConnell still has two main paths to getting a bill through the Senate (and ultimately to final passage). First, he could get all the moderates on board while losing only two from the far right. Then, back on the House side, if some Freedom Caucus members flip to “no,” their votes could be offset by House members who voted “no” on AHCA in May but now could hide behind the largely cosmetic changes in the Senate: this could allow the Republicans to eke out a narrow victory. In the alternative, McConnell could follow the path of the House, appease the far right and dare the shaky moderates to vote “no.”

One thing we do know for sure: Unless the GOP skeptics of the House bill face an outpouring of resistance in the next few weeks, we are likely to see not only a rollback of the progress made since 2009 but also a fundamental undermining of the health care safety net that has been in place since 1965. That ought to make America great again.

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

Another year means another LGBTQ Pride season, and another reason to celebrate significant gains in LGBTQ health thanks to the Affordable Care Act (ACA). What are we celebrating in 2017?

For one, more LGBTQ people have health insurance than ever before. Thanks to the ACA, the uninsured rate for low- and middle-income LGBTQ people is at a record low, dropping from a high of 34 percent in 2013 to 22 percent in 2017. Overall, the uninsured rate for this group of LGBTQ people fell by 35 percent since the ACA’s major reforms went into effect. Although we still have a lot of work to do to address LGBTQ health disparities—like higher rates of HIV and tobacco use—access to quality, affordable health insurance has helped our communities begin to close these gaps.

In addition, 2017 was the best year ever for transgender people to enroll in health insurance.  Thanks to a new ACA rule that went into effect in 2017, most private insurers can no longer include plan language that discriminates against transgender people (known as transgender exclusions) or otherwise discriminate against LGBTQ people in health coverage or care. This means that new insurance plans, while still far from perfect, are better than ever: our analysis in December 2016 found that the vast majority of silver marketplace plans in 16 states had removed transgender exclusions. Even better, nearly 20 percent of plans had language indicating that all or some medically necessary transition-related care would be covered. Although there is still more work ahead of us to improve health care for transgender people, this—plus the fact that 14 states and DC now affirmatively cover transition-related care in their Medicaid programs—shows significant progress.

Despite these gains, LGBTQ health is under attack. Instead of building on the progress the ACA made, members of Congress and the Trump administration want to take health care from millions, including an estimated 1 million LGBTQ Americans, and gut essential nondiscrimination protections. The American Health Care Act—passed by the House and currently under consideration in the Senate—would strip insurance from 23 million Americans, hike premiums by 20 percent next year, and cut $834 billion from Medicaid, all while eliminating protections for people with preexisting conditions. These are just some of the changes that Congress is considering to give tax breaks to the wealthy while cutting billions of dollars from programs that low- and middle-income LGBTQ families rely on.

At the same time, the Trump administration has threatened to roll back parts of Section 1557 of the ACA, which bans sex discrimination in health care programs that receive federal funding and is critical to ensuring that LGBTQ people are treated respectfully when accessing coverage and care. Because Section 1557 is not subject to the budget reconciliation process, Republicans in Congress cannot repeal this part of the ACA, so Section 1557 is likely to remain in place at least for the near future.

However, parts of the Section 1557 regulation—a rule issued by the Obama administration that was finalized in May 2016—have been challenged in federal court. The plaintiffs in the litigation, Franciscan Alliance v. Price, challenged the Obama administration’s interpretation that the ACA’s ban on sex discrimination prohibits discrimination based on sex stereotyping, including gender identity. Judge Reed O’Connor—the same judge who blocked the Obama administration’s efforts to protect transgender students—agreed with the plaintiffs and issued a nationwide preliminary injunction on December 31, 2016.

Although a setback, this injunction is temporary and applies only to the Office for Civil Rights at the U.S. Department of Health and Human Services (HHS). Under this ruling, HHS is barred from enforcing Section 1557’s protections for transgender people. However, the Section 1557 rule itself remains firmly in place. This means that covered entities, such as hospitals and state Medicaid programs, must continue to comply with Section 1557, and LGBTQ people continue to be protected from discrimination in health insurance and health care. We can’t emphasize this enough: LGBTQ people should never face discrimination and, if you do, you have rights and should contact Out2Enroll or a legal organization for help.

Advocates should also be aware that HHS has asked Judge O’Connor to stay the litigation to allow the Office for Civil Rights to reconsider the Section 1557 rule. We are currently awaiting his decision on this issue, but advocates should be prepared to educate and activate your networks about the importance of Section 1557 if and when the rule is reopened.

Thank you for everything you’re doing this Pride season—from spreading the word about enrollment at Pride festivals, to calling members of Congress to ask them to protect the ACA—and for your ongoing commitment to LGBTQ health. Out2Enroll and Community Catalyst will continue to keep you posted on new developments and what you can do to promote LGBTQ health equity.

Katie Keith is a member of the Steering Committee at Out2Enroll

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

As health advocates work tirelessly to defend the Affordable Care Act in a wildly contentious partisan climate, we simultaneously find bipartisan efforts to combat the opioid crisis. But today’s overdose problem is not the first time our country has faced a devastating drug crisis—and even though drug overdose death rates now exceed those due to firearms and cars, overdose deaths have been increasing since 1980. So why the unified response now? Many outlets are rightly pointing out that the social and political reactions we see in the current opioid crisis differ dramatically from the criminalized approaches of the 1980s “War on Drugs.”  

It’s important to look at how structural racism has contributed to the opioid crisis, and recognize that structural racism has also created the public motivation to try and do something about it.

What’s Different about the Opioid Crisis?

In short, the current opioid crisis has a different face.

The 1980s drug crisis was the “crack epidemic” and stereotypically portrayed as a phenomenon of “the violent black inner-city,” focusing on criminally dangerous drug addicts. Media coverage at the time shamed black mothers with addiction in particular, referencing “a time bomb in cocaine babies” and the “bio-underclass.” Crack was “reaching out to destroy the quality of life, and life itself, at all levels of American society.” In reality, the harm caused by the crack epidemic was not as severe as the media sensationalized. However, the resulting punitive approaches of the “War on Drugs” with harsh sentencing and mandatory minimums disproportionately affected communities of color with devastating effects.

Today, we're shown a different face in the opioid crisis – a white one. Since 2001, the opioid overdose death rate among non-Hispanic whites has been higher than that of non-Hispanic blacks, and has sharply increased in recent years. With this new face comes a new response: rather than demonizing substance use as criminal behavior, our nation emphasizes treatment and public health interventions.

Opioid Overdose Deaths by Race/Ethnicity, Age-adjusted Rates Per 100,000 Population

Timeframe: 1999 – 2015

Source: Opioid Overdose Deaths by Race/Ethnicity, obtained from kff.org

Why is the opioid crisis disproportionately affecting whites?

Non-Hispanic whites make up more than 80-percent of opioid overdose deaths in the United States, and structural racism plays an important role in explaining this. A major driver of the current crisis is over-prescription of opioid pain relievers. Research shows communities of color have poorer health insurance coverage, less access to care, and get lower quality treatment than whites. Whites therefore may be more at risk of opioid overdose since they – and likely their family and friends – are more apt to be engaged in the health system to begin with, and thus more likely to obtain prescription pain medication.

On the whole, racist stereotypes lead to different pain treatments for black and white patients. Whether it’s the untrue assumptions that a black patient’s pain threshold is higher than their white counterpart or that a black patient is more likely to divert prescription pain pills to the illicit drug market, there’s a structural racism in the way pain is managed in this country. 

How are the social and political responses different?

Studies show we are more likely to empathize with people who look like "us,” and policy-makers are more likely to be white. When law enforcement, elected officials and others in positions of power see themselves and their family members in opioid “victims,” they are more compelled to act with some compassion.

It’s why the punitive response to the crack epidemic has shifted to focus on treatment. Instead of criminals and selfish monsters, those misusing opioids are victims who need help.

One former narcotics officer described his new outlook:

“The way I look at addiction now is completely different…I can’t tell you what changed inside of me, but these are people and they have a purpose in life and we can’t as law enforcement look at them any other way…They need help.”

Substance use disorders have been affecting diverse communities for decades, but we are now focusing on the opioid crisis as a window of opportunity for shifting important public health policy. And in the words of Ekow Yankah, Law Professor at Yeshiva University:

It is hard to describe the bittersweet sting that many African-Americans feel witnessing this national embrace of addicts. It is heartening to see the eclipse of the generations-long failed war on drugs. But black Americans are also knowingly weary and embittered by the absence of such enlightened thinking when those in our own families were similarly wounded. When the face of addiction had dark skin, this nation’s police did not see sons and daughters, sister and brothers. They saw “brothas,” young thugs to be locked up, rather than “people with a purpose in life.”

So, what do we do now?

We should not ignore the very real devastation of the current opioid crisis. Nor is the answer to structure health advocacy efforts solely on opioids, perpetuating the notion that because the problem has a “white face,” more people will care. That will only promote the structural racism we already see in our social, legal, political and health systems.

Instead, we need to employ a health equity approach by promoting policies that will equally benefit diverse populations: communities of color and white communities, rural and urban, young and old, wealthy and disadvantaged. We need to use a strategy that says “We don’t have to wait until a problem has a white face to answer with humanity.” This means calling out specific injustices when we encounter them, including Attorney General Jeff Sessions’ return to punitive policies for drug crimes. It also means building diverse coalitions to promote our policy issues.

Specific to substance use disorders policy, this also means advocating for treatment and prevention policies that refer to all substance use, and not opioids alone. To do anything else will continue to elevate the health of white people over communities of color.

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

Our advocacy around race and health requires us to address racism as a cause of poor health, recognizing that without addressing this root cause, attempts at solving health inequities will continuously fall short. However, in order to bring full awareness to the consequences of racism on health outcomes, we must take a step even further back, and address the ways structural racism is embedded in health policy and health advocacy. When the foundations for the health advocacy strategies that shape our policies are flawed, we build structures that benefit some people above others. We then spend the rest of our time and energy trying to find resources for how it can benefit everyone that was left out, repeatedly finding that these systems do not work for people they weren’t originally built for. In doing health advocacy work, I am often taken back to childhood memories of translating important medical information and conversations between doctors and my mother, both of them speaking a different language in more ways than one, and even then I understood that the health care system was just one more place where we, a family of immigrants, didn’t belong. The system wasn’t made for us, and therefore very seldom did it meet our needs.

The story of health policy in the U.S. continues to be one of racial discrimination in coverage access and health care delivery, and advocates often find themselves fighting the same battle on many fronts. Even when health policy shifts towards racial inclusion we see that the impetus for the shift is often tied to the sudden realization that the issue also impacts whites. Take for example, conservative white America’s newfound support for the Affordable Care Act- Judy Lubin, a sociologist and adjunct professor at Howard University in an interview with CNN described the recent shift: “Americans now realize Obamacare helps millions of working class whites and that it's not as once portrayed by conservatives a form of welfare pushed by the first black president to help people of color.” As health policy advocates working tirelessly to preserve the ACA and the coverage it provides millions of Americans, we must find ways to showcase the new voices of conservative whites without drowning out the ones of people of color whose sustained support helped pass and implement the law and whose lives will be disproportionately affected by its loss.

One way health policy advocates can stand against structural racism is by continuing to center our work on health equity, especially while in campaign mode. It is in these moments of chaos that we must ensure that the need for a “win” does not come at the expense of sidelining voices of color. The win that comes at the expense of marginalized people does not effectively support those people in the end. Instead, it guarantees that we will get less than what we need, and we will have compromised our values to get there. Take for example the current campaign to save the ACA, one where we recognize that those most likely to be hurt by a repeal are the voices least likely to have any sway with most Republican members of Congress. However, if we allow policy advocacy and negotiations to meet the standard of who is most likely to be heard, we fail all of the people who already feel left out of the process.

Equitable health advocacy requires that we build coalitions and the collective power necessary to ensure health policies serve diverse populations. Strategic power building elevates the voices of those most likely to be heard as a tool for bringing into the conversation those historically silenced. When equitable health advocacy is used to promote policies not on behalf of but rather in partnership with communities of color, we reset the expectation of who advocacy works for. This is the only way we can avoid elevating the plight of white people in hopes that there will be leftover resources for people of color. As a health advocate, and a person of color, I understand that through my proposed strategy approach of all of us - not just some of us. When we lose, we all lose. However any strategy that doesn’t see people of color as essential to the fight, also guarantees that even when there is a win - people of color continue to lose.

Only through the intentional inclusion of diverse communities can we continue to take active steps to interrupt and dismantle systemic racism. By working with government agencies across sectors, health care providers and  community leaders we can identify opportunities for equitable health policies and create innovative strategies for addressing disparities as well as the continual investment in the health and success of communities where racism actively disrupts progress.

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

The American Health Care Act (AHCA), as passed by the House of Representatives and sent on to the Senate, would make draconian cuts to Medicaid funding and reduce the federal minimum eligibility level for children ages six to 19 from the current 138 percent, to 100 percent, of the federal poverty level. That translates to an income of $20,420 or less for a family of three. These changes would reverse the progress on children’s coverage that has been made through the ACA and dramatically undermine critical services for children and families across the country, especially low-income children and children with special needs. Data continues to emerge as to how terrible this bill is – from estimates on the burden it would place on state budgets to the financial impact on schools that provide health services to children enrolled in Medicaid, resulting in reduced access to care, especially for children with disabilities. The Congressional Budget Office’s newly-released estimates confirm both the financial losses for states and the human impact of the AHCA—14 million could potentially lose their access to Medicaid by 2026.  

Today, in a new report, the Institute for Child, Youth and Family Policy at Brandeis University – explores the racial and ethnic breakdown of these potential coverage losses for children. The results are stunning for Black and Hispanic children across the country.

The fate of the House bill now rests with the Senate.

VIEW THE NEW REPORT

 

What does the data show?

Both the actual number, and disproportionately high share, of coverage losses for Hispanic and Black children is significant nationwide, with some of the greatest impacts concentrated in Southern states. The table below shows the top ten states facing a decline in number of children that meet the federal eligibility minimum:

California, Texas, Florida and Georgia are among the states with the largest declines in the number of children eligible for Medicaid under the House version of the AHCA, ranging from 462,500 Hispanic children in California to 88,200 Black children in Florida (Table 2). Looking at these numbers expressed as the percentage of children of color in a given state who would lose access to their current Medicaid coverage paints the threat more starkly. Tennessee would be the state with the largest decline in the percent of Hispanic children federally eligible for Medicaid under the AHCA proposal, with a 20.4 percentage point decline, followed by Wisconsin at 19 percent. For Black children, Utah and Kansas rank first and second in their percentage point decline in children federally eligible for Medicaid, at 17.3 percent and 15.9 percent, respectively.

What do these numbers mean?

The GOP bill, now being worked on behind closed doors and without public hearings in the Senate, reverses the impressive coverage achievements made possible by the partnering of the ACA, Medicaid and CHIP. For children of color, the impact could not be clearer: hundreds of thousands of children of color stand to lose access to vital health care helping them thrive, made possible by their Medicaid coverage. This is close to 10 percent of the school-aged population – about 5 million children. School-aged children’s loss of coverage is particularly troublesome because of Medicaid’s Early Periodic Screening Diagnosis & Treatment (EPSDT) benefit that ensures access to critical preventive services and care. In sum, this step backwards for our country would explicitly and disproportionately harm children of color in the near-term and exacerbate troubling long-term health inequities across our country that many of the ACA’s provisions have just started to address. 

What can advocates do?

Advocates can take a dive into their own state-level data to understand the health equity impact of the school-aged proposed rollback. Learn more about your state here. Amplify the data and tell the personal stories of children in your state. Be specific about which racial and ethnic groups will suffer and could lose access to important preventive services because of AHCA. Effective storytellers can include teachers, school nurses, caregivers, providers, parents and youth. Policy makers need to hear from us to help them fully understand how their actions on this dreadful piece of legislation will determine the future of progress on health equity in the United States.

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

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

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

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

A wakeup call for America’s governors

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

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

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

Additional cuts targeted at children

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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