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

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
Georgetown University Health Policy Institute & National Council of La Raza, January 2016

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.



By Don McCanne, M.D.

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 choice.

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.)