Health Care Law and Latinos

1. Health Care Law and Latinos Victoria Sorlie-Aguilar Family Physician Oxnard, California March 2011

2. Overview In the Exam Room: Adela’s Story Adela’s Story after the Affordable Care Act What about the undocumented?

3. Adela’s Story A Day in the Life of the Uninsured: California Academy of Family Physicians Magazine October 2008

4. Before ACA: ER care Adela is beautiful 53 year-old Latina who had no idea she had elevated cholesterol, hypertension or diabetes until the day she landed in an E.R with stroke symptoms. Right arm went limp and she couldn’t speak

5. Before ACA: No medical home Head CT was interpreted as normal She was diagnosed with TIA (transient ischemic attack), hypertension, diabetes and discharged from the hospital ---and told to follow-up with her primary care doctor Being your average divorced mom and working full-time to make ends meet; she had no health insurance much less a primary care doctor.

6. Before ACA: fragmented care At the clinic she was tearful. Adela had been referred to physical therapy for arm pain and had been scheduled a pap smear at my clinic. “But what is wrong with my arm?” ER report reads “transient ischemic attack” which implies that the attack was temporary or resolved

7. But in the clinic Adela’s speech is slurred as if she’s intoxicated. Her daughter who accompanied her adds “she doesn’t usually sound like that” Adela nods frustrated. Today’s Physical Exam (Prevention) reveals there is a problem with her balance and coordination. Likely she has had a small stroke often hard to find on CT scans.

8. Fragmented Care Adela is confused, “I’ve been healthy for all these years…” Adela’s last visit with a doctor was four years ago for a pap smear only. (free for all low income women under the BCDP program) Weeks later, an MRI of her head confirms the diagnosis: Brainstem stroke!

9. An ounce of prevention worth a pound of cure Hypertension: the “silent killer” High Cholesterol: You can’t feel it until it’s already done damage Diabetes: no symptoms until advanced All easily diagnosed with routine visit and labs Adela is a tragic example of why we need ACA

10. Without Health Reform LAW • 14% of Hispanics have been diagnosed with Diabetes compared to 8% whites • Many with diabetes remain undiagnosed especially those without access to health care If current trends continue 1 in every 2 minority children born today will develop type 2 DM at some point in their lives! Center for American Progress “Easing the Burden 2010”

11. A new dawn…life after ACA

12. 2010 Insurance Reforms Establish a temporary national high-risk pool to provide health coverage to individuals with pre-existing medical conditions. (Effective 90 days following enactment until January 1, 2014) Adela: with stroke, DM, HTN, Chol, and limited choices can join the Hi Risk Pool in California now

13. 2010 Insurance Reform Require qualified health plans to provide at a minimum coverage without cost-sharing for preventive services, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women. Adela’s PAP, mammogram, physicals, approved disease screening is INCLUDED with her insurance, not extra!

14. Adela would get regular complete physicals plus mammograms. Her primary doctor would notice her elevated blood pressure and screen her for diabetes and cholesterol when she was 35. They would find her cholesterol and blood sugar too high. Her primary doctor would start 3 simple medications. Adela never suffers a preventable stroke!

15. 2011 Medicare Changes Improve access to care by increasing funding by $11 billion for community health centers and by $1.5 billion for the National Health Service Corp Provide a 10% Medicare bonus payment to primary care physicians, and to general surgeons practicing in health professional shortage areas. Adela chooses a clinic in her rural town, there are plenty of doctors and she gets an appointment when she needs it, NOT 3 MONTHS later!!

16. 2014 State-Based Health Exchange Create state-based Health Exchanges through which individuals and small businesses with up to 100 employees can purchase qualified coverage. As a fulltime worker whose job doesn’t offer health insurance. Adela shops for insurance in her states “health exchange”.

17. 2014 ACA: Reduces out-of-pocket limits for those with incomes up to 400% FPL 100-200% FPL: $1,983/individual $3,967/family in 2010 200-300% FPL: $2,975/individual $5,950/family in 2010); 300-400% FPL: $3,987/individual $7,973/family in 2010) Adela can afford to purchase insurance.

18. 2014 Insurance ReformRequire guarantee issue and renewability and allow rating variation based only on Age Premium rating area family composition and tobacco use 2014 NO ANNUAL LIMITS OF COVERAGE Adela can not be dropped from her plan or have her premium skyrocket for having diabetes or a stroke!

19. What about the undocumented? • Reform Law: does not cover the undocumented • Only emergency (Medi-Cal) • Many counties don’t cover undocumented in indigent programs CHECK YOUR CALIFORNIA COUNTY AT CHCF WEBSITE: ww.chcf.org/publications/2009/10/county-programs-for-the-medically-indigent-in-california

20. Mexican Immigrants Over 2/3 of Mexican immigrants working in jobs that are heavily reliant on Mexican immigrants have no medical insurance coverage Only 5% of employed Mexican immigrants are covered by Medicaid and other public insurance www.healthpolicy.ucla.edu/pubs/files/immigration_rep_Oct07.pdf

21. California has the largest population of Migrant/Seasonal Farm workers 1990 CA 1,362,534 TX 500,138 FL 435,373 2000 CA 1,302,797 TX 362,724 FL 286,725 1990 Atlas of Migrant and Seasonal Farm workers NCFW 2000 Farm worker Enumeration Study NCFW

22. Farm work accounts for 13% of all workplace fatalities, making it one of the most dangerous occupations in the U.S. http://www.healthpolicy.ucla.edu/pubs/files/immigration_rep_oct07.pdf

23. Where do the undocumented receive care? Safety Net Providers Public/ Non-Profit Hospitals Community Health Centers (41%) non-citizen, non-legal permanent resident Hispanics state that their usual provider is a community clinic or health center. (US DHHS 2008) County Clinics Sliding Scale, Fee for Service, Family Pact, BCDP (limited scope)

24. Safety Net: Community Clinics 2008: 78% of primary care visits at community clinics were made by safety net patients (56% Medi-Cal or Healthy Families) (22% by uninsured/indigent) 6% Private Insurance California Healthcare Foundation Safety Net Facts and Figures 10/2010

25. ACA and Latinos Easing the Burden: Center for American Progress December 2010 Funding to establish more Community Health Centers (where uninsured go for care) Funding to National Health Service Corp (more docs practice in shortage areas) Funding for Teaching health centers: Primary care residencies in community based clinics (more clinic docs trained)

26. ACA and Latinos Easing the Burden: Center for American Progress December 2010 Initiatives to increase health workforce diversity: scholarships/assistance to disadvantaged students who commit to work with underserved Grants to states, hospitals, public health depts, clinics to promote to use of community health workers in medically underserved areas (peer outreach) Support for development of cultural competency curriculum in health professional schools

27. References • A Day in the Life of the Uninsured: California Academy of Family Physicians Magazine October 2008 • KFF Health Reform Timeline: www.kff.org/healthreform/8060.cfm • Easing the Burden Center for American Progress www.americanprogress.org/issues/2010/12/easing_the_burden.html • Migration Health And Work Facts Behind the Myths: October 15, 2007 - University of California, et al HIA • California Health Care Foundation: Safety Net Facts and Figures October 2010 • National Center For Farm worker Health: www.ncfh.org Demographics • U.S. DHHS Health Centers Americas Primary Care Safety Net www.hrsa.gov/bphc/HRSA_HealthCenterProgramReport.pdf