Wednesday, January 20, 2016

qotd: More Hispanic children covered, but do we need a public option?

Georgetown University Health Policy Institute
& National Council of La Raza
January 2016
Historic Gains in Health Coverage for Hispanic Children in the
Affordable Care Act's First Year
By Sonya Schwartz, Alisa Chester, Steven Lopez, and Samantha Vargas Poppe

Key Findings

1. Uninsurance rates for Hispanic children reached a historic low in the
first year that the Affordable Care Act's (ACA) coverage provisions took
effect. The number of uninsured Hispanic children dropped by
approximately 300,000 children, from about 2 million uninsured Hispanic
children in 2013 to 1.7 million in 2014. The uninsurance rate for
Hispanic children declined by nearly 2 percentage points from 11.5 to
9.7 percent in the same one-year time period.

2. Hispanic children were much more likely to have health coverage in
states that have taken multiple steps to expand coverage for children
and parents. In 2014, 20 states had uninsurance rates for Hispanic
children that were significantly below the national average. Of these,
16 states covered children in Medicaid and the Children's Health
Insurance Program (CHIP) above 255 percent of the Federal Poverty Level
(FPL, the median eligibility level for children), 18 states provided
Medicaid and/or CHIP coverage to lawfully residing children in the
five-year waiting period, and 17 states extended Medicaid to low-income
parents and other adults.

3. Despite these gains, health coverage inequities for Hispanic children
remained. Hispanic children accounted for a much greater share of the
uninsured child population (39.5 percent) than the child population at
large (24.4 percent) in 2014. These inequities existed even though the
vast majority of uninsured Hispanic children were eligible for Medicaid
and CHIP, but unenrolled.


Comment by Don McCanne

They say that the historic gains in health coverage for Hispanic
children is one of the many accomplishments of the Affordable Care Act
(ACA) that we can celebrate. From 2013 to 2014 the number uninsured
Hispanic children declined from about 2 million to 1.7 million.

Of course, under a well-designed single payer system, that number would
have dropped to zero, not only for Hispanic children, but for everyone.
Yet, now that single payer has been thrust back into the political
debate, the sides are lining up between those who say that we should try
to build on ACA and those who say that we should move to single payer,
improved Medicare for all.

Now be real. With ACA, we have reduced the number of uninsured Hispanic
children by about 300,000. What kind of adjustments would we have to
make in ACA to insure the other 1,700,000? With greater outreach to the
eligible children, we might be able knock that number down a little bit
more, but there is no mechanism under ACA, even if tweaked, that we
could use to come anywhere near eliminating uninsurance.

The ongoing, highly publicized debate between two potential presidential
candidates has produced a surge in interest in single payer, according
to several polls. There is now a spate of opinion articles being written
by progressives who have previously acknowledged the straightforward
benefits of single payer. Ironically, many of these articles represent a
retreat, taking the position that we have gained much with ACA and we
should continue to build on it, that single payer is not politically
feasible. Yet none of them have even hinted at the policies they would
propose that would be truly effective in achieving the same goals as
single payer, except maybe for the fantasy fix of the public option.

The public option would be only one more player in our dysfunctional,
administratively complex, multi-payer system, and an expensive one at
that. If it were a Medicare buy-in, would new enrollees be placed in the
same risk pool as the elderly and people with long-term disabilities?
That would require very high premiums because of the greater needs of
these patients. Also Medicare covers only about one-half of health care
costs and works only because almost everyone has some additional
coverage such as Medigap, employer-based retiree coverage, Medicare
Advantage, or Medicaid. So would people have to buy two plans - the
Medicare buy-in plus some sort of Medigap plan? Too expensive and
administratively wasteful. If the buy-in were a Medicare Advantage plan
insurers would be reluctant to enter that market since it is subject to
adverse selection and a death spiral because of the high premiums they
would have to charge. Besides, Medicare Advantage plans are private
plans and could hardly be categorized as a "public" option. Instead of
using Medicare, could we start with a new government-run insurance plan?
We would want to have reasonably comprehensive benefits, with a higher
actuarial value to avoid excessive out-of-pocket costs, and we would
want free choice of our health care professionals and institutions, all
with no underwriting (subjecting it to adverse selection). Since the
government would require that it be budget-neutral, the premiums of such
a plan would be much higher than any plan currently on the market.
Forget that. Okay, so let's offer an affordable public option that has
spartan benefits, low actuarial value (high deductibles, etc.), and
limited choice of narrow networks. Wait a minute. Isn't that where ACA
is taking us? Do we really want the public option to be just another
player on the ACA exchanges? How could that ever be considered an
incremental step that would bring us closer to single payer?

Back to those 1,700,000 uninsured Hispanic children. Do we want all of
them insured, along with everyone else? It will never happen under ACA
since thousands of tweaks would not be enough to make it an effective
financing system that would take care of everyone. The fundamental ACA
infrastructure is irreparably flawed. We have to let these sheep in
progressive clothes - the aforementioned opinion writers - know that
they are flat-out wrong. Instead of whining about feasibility, we need
to change the politics so that single payer becomes the only feasible

Or shall we simply continue on the ACA path and adopt some more tweaks
so that in the next decade or so we can get maybe another 300,000
Hispanic children insured? And the other 1,400,000 Hispanic children?
Under single payer, we wouldn't have to ask that.

(Note: While we are battling for single payer, we do need to continue
tweaking ACA. California's Health for All Kids law will allow about
170,000 of the state's 497,000 uninsured children to quality for
Medi-Cal, plus many others are already qualified but do not enroll. But
we cannot allow ACA tweaking to in any way diminish our drive toward
national single payer.)

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