March 23, 2010
The health care bill that President Obama is signing today is a far cry from our initial vision for universal medical coverage. Undocumented immigrants remain excluded; anti-choice forces cynically use health care to advance their misogynist agenda; and the paradigm that health care is about profit, not people, remains unchallenged.
Did we lose? Have we failed?
No. This legislation is a first step in fixing a broken health care system and improving the lives of millions of people of color.
When it goes into effect, the law will expand the eligibility of the Medicaid program to people earning 133 percent of the Federal Poverty Level or less (currently that's set at $18,310 in yearly income for a family of three). Many states have more generous eligibilities than the federal one, but others do not. The federal expansion then sets a new floor for states. This will be especially meaningful in conservative states since now everyone in every state earning 133 percent of the Federal Poverty Level or less is eligible for Medicaid.
The legislation will also expand Medicaid eligibility to adults who have no children and who've faced more restricted access in the past; this will be especially important for younger Americans and men of color. According to estimates from the Congressional Budget Office, almost a quarter of Americans who don't have health insurance today will be covered under Medicaid over the next 10 years.
The Medicaid expansion is critical for communities of color. More than a half of the country's uninsured are people of color, according to data from the Kaiser Family Foundation, and that rate would be even higher if it weren't for public insurance programs such as Medicaid. Twenty percent of nonelderly Blacks are uninsured and 30 percent depend on Medicaid or other public programs. The numbers are comparable among Latinos and Native Americans: 26 percent and 28 percent, respectively, use Medicaid or similar programs. Whites, by comparison, have greater access to jobs and as a result to employer-based insurance. Only 13 percent of whites depend on public programs and only 13 percent live without insurance.
What the new law doesn't do for Medicaid unfortunately is resolve problems at the state level.
Each state decides how to administer the program with federal dollars. While the legislation increases how much the federal government is spending on Medicaid it doesn't alter how much or how little states are putting in. The program's chronic budget problems have to do with states not being ale to afford their piece of the pie and the federal law doesn't address this. This also means that depending on the state they're in, patients may still find it hard to get a doctor who takes Medicaid.
Two other features of the new law will be important for communities of color.
Employers with more than 200 employees will now have to offer health benefits to all of them, even low-income ones, and those with at least 50 employees would be required to pay a fine if they don't offer health insurance. Also, businesses with at least 50 employees who impose a waiting period before employees can enroll in coverage would have a sliding scale fine based on the length of the waiting period. This will be important for people of color who are overrepresented in these low-income jobs.
One of the most discussed elements of the new legislation is a ban on denying or rescinding coverage based on pre-existing conditions. As it stands now, private insurance companies may deny or cut off people who are older or sicker if they had a medical illness prior to application or enrollment. Given that communities of color are more likely to experience chronic illness because of a lifetime of being denied health care access, these insurance industry practices disproportionately harm them. The proposal would ban this practice and make it easier for people to get and to keep health insurance.
While the legislation President Obama is signing today is less than our desired ideal, this will be a lifeline for millions of people of color who are now blocked from getting health care services they desperately need. The real danger moving forward will be in thinking that the work is done when in fact it has just begun.
Flávio Casoy, MD is a resident psychiatrist in San Francisco, CA