Threats to Obamacare could deal a new blow to communities of color that have been disproportionately ravaged by the coronavirus pandemic as the nation is reckoning with generations of inequity.
The Affordable Care Act’s insurance subsidies, its expansions of Medicaid eligibility and its protections for preexisting conditions have especially helped Americans of color, narrowing historic disparities in access to health insurance and affordable care. The coverage gains are among the most significant since the passage of Medicare and Medicaid and the desegregation of American hospitals more than 50 years ago.
Now, President Donald Trump is again threatening to replace the law if he’s reelected. And exactly one week after the election, the Supreme Court, with its new 6-3 conservative majority, will hear oral arguments in a case brought by conservative states seeking to overturn the entire Affordable Care Act. If the law is dismantled, the communities it aided the most stand to lose the most.
“Health care could be ripped away from millions and the numbers of uninsured Americans of color could skyrocket—aggravating the health care disparities that already exist in this country,” said Sen. Tammy Duckworth (D-Ill.). “It’s especially infuriating that this is happening in the middle of a deadly pandemic that is disproportionately devastating so many seniors, Black, Brown and Native Americans and those with pre-existing conditions.”
Between 2013, the year before the Obamacare markets opened and Medicaid expansion began, and 2018, the rate of Latinx adults without health insurance plummeted from 40 percent to 25. The uninsured rate for Black adults fell from 24 percent to 14. For white adults, it dropped from 15 percent to 9, according to the Commonwealth Fund.
“There is no doubt that the Affordable Care Act, though it left millions uninsured, narrowed the racial gap in health insurance coverage and that’s a good thing,” said Mary Bassett, the former New York City health commissioner who is now a professor at Harvard’s School of Public Health. “Having millions suddenly lose their health insurance seems very likely to have an adverse impact.”
If the health law disappeared, the Urban Institute estimated that the gaps would widen once again, almost back to 2013 levels. And that assessment was in 2019 — before the devastation wrought by the coronavirus which is exacerbating inequality, in both health and the economy overall.
Especially affected would be people of color living in one of the 38 states that expanded Medicaid, the joint federal-state health program for low-income people. Without health coverage, many would lose access to much-needed care for chronic health conditions — and become more vulnerable to serious complications from Covid-19.
Trump says he wants a health system that will give people more choice, at less cost. “It’s in court, because Obamacare is no good,” he said at his second and last debate with Democratic challenger Joe Biden.
Even the Affordable Care Act’s backers admit it was not a panacea. Health inequities, some driven by generations of systemic racism, persist. Private insurance remains out of reach for many people who earn too much to get Obamacare subsidies — but too little to afford buying coverage on their own. High deductibles and narrow provider networks also limit access to care, with minorities often facing bigger obstacles and fewer choices.
Yet the law has helped reduce the racial gap among those who said cost made it harder to receive care. In 2013, 23 percent of Black Americans, 28 percent of Hispanic Americans and 15 percent of white Americans reported avoiding care because of cost. In 2018, those numbers had dropped to 17.6 percent, 21 percent and 13 percent, respectively. As of September, one-fifth of nonwhite adults were struggling with long-term medical debt. More than 60 percent of them were fearful that one major health event could send them into bankruptcy, a Gallup poll found.
“It’s been well-established at this point that one of the biggest impacts that health insurance has is that it improves your household finances and protects you from unexpected medical bills, which can be really devastating,” said Sarah Miller, an economics and public policy professor at the University of Michigan.
Losing Medicaid coverage would be especially hard on communities of color, which also have been disproportionately affected by layoffs during the pandemic.
“The part of the economy that’s been hurt the most is the service sector,” said Jennifer Wagner, director of Medicaid eligibility and enrollment at the left-leaning Center on Budget and Policy Priorities. “That sector has a disproportionate number of people of color. They are the ones not working in restaurants or at the hotels. They were kind of on the brink to begin with and Medicaid was their backstop when they were between jobs.”
Better access to medical care, preventive screenings and Obamacare’s protections for preexisting conditions have helped narrow the racial gap for some health outcomes — though minority communities generally still bear an outsize burden of chronic disease.
For instance, researchers found that before the ACA, African Americans with advanced cancers were 4.8 percentage points less likely to begin treatment within 30 days compared to whites. Those discrepancies were mostly erased in states that expanded Medicaid.
“The resulting increase in coverage has improved the lives and health of African Americans,” said Rep. Robin Kelly (D-Ill.) a member of the Congressional Black Caucus. “Most notably, the American Cancer Society linked it to a massive drop in the excessive cancer death risk faced by African American men.”
In Medicaid expansion states, there were also gains in reducing the risk of amputation in people with diabetic foot ulcerations, as well as improvements in infant mortality and maternal mortality rates. States that did not expand Medicaid experienced a slight increase in infant mortality. The gains were concentrated among Black mothers and children.
“While the condition of women before becoming pregnant is important to pregnancy, a lot of what happens is amenable to medical care,” Bassett said. “It’s likely that advances in infant mortality are … because people have insurance.”
Whether or not the Supreme Court strikes down the law, the outcome of the presidential election will determine the scope of health insurance coverage in the U.S.
Under Trump, the ranks of the uninsured have increased. In 2019, nearly 30 million Americans were uninsured at some point during the year, up about 1 million from the year before, according to the Census Bureau. It was the third consecutive yearly uptick, and marked a 10 percent increase from 2016 — though insurance rates were still higher than before Obamacare.
Latinx communities saw the largest declines in coverage under Trump, which immigrants rights groups believe is tied to the Trump administration’s crackdown on undocumented people. Though undocumented people aren’t eligible for Medicaid, they are allowed to purchase insurance under Obamacare. The Hispanic uninsured rate ticked up in 2019 to 18.7 percent from 17.9 percent in 2018.
Trump is likely to keep chipping away at the ACA if he wins reelection. He has already weakened it by allowing people to buy insurance plans that don’t comply with Obamacare rules. They are cheaper — but they offer skimpier coverage and fewer protections. His administration has also supported Medicaid work requirements, which courts have so far blocked. Those too would hit nonwhite adults.
“People of color disproportionately work in a low-wage industry,” Wagner said. “They have jobs with variable hours. They cycle in and out of the labor market more than the rest of the population. All of that is a recipe for disaster when it comes to work requirements.”
A second Trump term would almost certainly mean limited outreach and marketing, which Obamacare supporters say has stifled enrollment. Even during the pandemic, the president refused to expand the open enrollment period or advertise that the law could act as a safety net for the newly unemployed, a move that surprised some of his own health officials. The next enrollment season starts Nov. 1, but there hasn’t yet been a big push to get people to sign up.
“Navigators, assisters and even insurance agents, they were supposed to be trained to understand what has prevented these groups from accessing health coverage,” said Daniel Dawes, director of the Satcher Health Leadership Institute at Morehouse School of Medicine said. “But 90 percent of the funding was eliminated.”
In contrast, Biden is promising to expand on Obamacare, proposing a public option that would auto-enroll low-income people who lose their jobs and giving other people a new choice for getting covered. Biden also proposes lowering the Medicare age to 60, which would further reduce the uninsured gap, and doubling investments into community health centers.
POLITICO Live is hosting “Beyond COVID-19: Closing the Racial Health Gap” on Thursday, Oct. 29 at 1 p.m. ET. This is the second town hall in the “Confronting Inequality in America” series. You can register here.