By Olveen Carrasquillo, MD, MPH

The NiLP Report (May 2, 2017)

Ever since the House released their plan for Repeal and Replace of the Patient Protection and Affordable Care Act (a.k.a. ObamaCare) nearly two months ago, I have been fielding tons of questions on what would be the impact on Latinos.

A good place to start is examining what ACA did for the Latino community. The last quarter of a century saw a doubling of the Latino uninsured, rising from 6.9 million in 1989 to 13.2 million in 2013. Then in 2014, when the insurance provisions of ACA finally began, we saw for the first time a sizable dent in that figure. In two years the number of uninsured Latinos dropped by 4.1 million and the percent of uninsured Latinos went from 24.4% to 16.1%.

Dr. Carrasquillo with a patient

The gains in coverage were attributable to both a 3.9% increase in those covered by government insurance (through Medicaid) and a 6.9% increase by those having private insurance (through the ACA Exchanges). Thus, the standard party line has been “No demographic group has benefited more from ACA than Latinos.” As a result, most Latino health advocacy organizations have been strong supporters of ACA and among the leading critics of Repeal and Replace.

Arguments for Latino opposition to Repeal and Replace were further supported by last month’s Congressional Budget Office estimate of Repeal and Replace. That CBO analysis showed that Repeal and would increase the number of uninsured by 14 million within one year. Additional future changes to Medicaid and reduction in subsidies for the Exchange would increase the uninsured by 21 million in 2020 (and 24 million by 2026). This includes 14 million fewer Medicaid recipients by 2026.

My back-of-the-envelope calculations suggested under Repeal and Replace, about one million Latinos would lose coverage next year and about 2-3 million Latinos who gained coverage under ACA would lose it by 2026. This devastating impact on our community was the reason all Latino Democrats and even some moderate Republicans (such as Ileana Ros-Lehtinen) opposed Repeal and Replace.

Ultimately, the bill failed to garner enough supporters. Surprisingly the group that took the most blame for the bill not passing was the rightwing Freedom Caucus of the Republican Party. That group also ardently opposed the bill but for the opposite reason: they did not think it went far enough in reversing the gains made under ACA.

In response last week, Tom MacArthur (R-N.J.) released plans for a revised bill having the approval of the Freedom Caucus. Under these right wing revisions, states can charge older and sicker people even more for coverage than the original version, it further reduces benefits for those who purchase coverage and makes it even harder for low-income individuals to qualify for Medicaid benefits.

With these revisions, many Republican’s are expressing renewed confidence that now that they have placated their rightwing colleagues and feel that a revised bill can finally pass. With these revisions, I estimate thatat least 3 million Latinos who gained coverage under ACA would lose it (reversing nearly 75% of the gains made under ACA). We are now again being called upon to double up on defending ACA and opposing the devastating impact this bill would have on our communities.

Should we? Much to the dismay of many, my response is not so fast. To begin with, these numbers can be diced in many different ways. While the number of Latino uninsured decreased by over four million, it still left over 9 million Latinos without coverage. Framed another way, the majority of uninsured Latinos (70%) did not benefit from ACA insurance expansions. Further, Latinos continue to make up nearly a third of the uninsured population in the US and remain twice as likely as non-Hispanic whites to lack coverage. 

Who got left out? To begin with, about 4 million Latinos who are “undocumented.” Although Democrats and Republicans disagree on many aspects of ACA, most were unified that undocumented immigrants would get no benefit from ACA. The grumblings by several Latino representatives on this issue were rapidly dismissed by the Democratic leadership.

There are also about 1 million Latinos who would be eligible except for the fact they live in States like Texas and Florida. Those states, heavily dominated by Republican leaders, passed up on very generous federal subsidies to expand Medicaid to ensure their firmly-held beliefs that low-income people should not receive any benefits under ACA.

Other Latinos also left out are those for whom the costs of coverage were still too high. Surveys of Latinos who attempted to purchase insurance through the exchange but ultimately did not, found that 70% felt that despite partial subsidies, they still could not afford coverage.

There is one more not so subtle issue. ACA was yet another step towards institutionalizing disparities in health coverage. Coverage through Medicaid or the exchanges is much better than being uninsured, but a far cry from high-quality, comprehensive coverage those of us lucky enough have full private coverage enjoy. Two weeks ago the CEO of the Mayo Clinic was blasted for publicly stating a well know dirty little secret that the health system gives preference to patients with private insurance over those with Medicaid. His statements are consistent with the large volume of research showing Medicaid recipients have much worse access to care than the privately insured.

For those receiving coverage through the Exchanges, the actuarial values of many of those plans are only 60-70%. This means persons purchasing them often face much higher deductibles and co-payments than most insured through other private plans. So, yes, Medicaid and plans from the Exchange are a step up from being uninsured but by no means equitable, leading to such persons often being treated as second or third class citizens by health systems.

Lastly, ACA did nothing to address the large inequities in Medicaid and Medicare financing for the 3.5 million Latinos living in Puerto Rico. When the Puerto Rico Financial Recovery Board met last month, they recommended slashing teacher pensions to improve the island’s finances. However, they did not include addressing this major financial inequity in their list of recommendations.

I often bring up these points at public discourses. My otherwise liberal friends quickly respond, “Do not let the perfect be the enemy of the good,” “Sometimes we have to make compromises/sacrifices” (which, of course, means they are willing to sacrifice ‘them’ ), and “Yes, those are very important issues. This is just a start. We need your support now and we will get to addressing those issues later.”

Most telling was two years ago when a very senior Health and Human Services official was visiting Miami and I challenged her on the issue of the undocumented being left out of ACA. Her response was “Of course the Obama administration cares deeply about the health care needs of the undocumented. It is just so sad that politically there is nothing we can do about it. This is why we have no plans of trying to address this anytime soon.”

Now lets us get out there and defend ACA!!!