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

Health Care Law and LatinosHealth Care Law and Latinos

Victoria Sorlie-Victoria Sorlie-AguilarAguilar

Family PhysicianFamily PhysicianOxnard, CaliforniaOxnard, California

March 2011March 2011

OverviewOverview

In the Exam Room:In the Exam Room:

Adela’s StoryAdela’s Story Adela’s Story after Adela’s Story after

the Affordable Care the Affordable Care Act Act

What about the What about the undocumented?undocumented?

Adela’s StoryAdela’s Story

A Day in the Life of the Uninsured: California Academy of Family Physicians Magazine October 2008

Before ACA: ER careBefore ACA: ER care

Adela is beautiful 53 year-old Latina Adela is beautiful 53 year-old Latina who had no idea she had elevated who had no idea she had elevated cholesterol, hypertension or diabetes cholesterol, hypertension or diabetes until the day she landed in an E.R until the day she landed in an E.R with stroke symptoms. with stroke symptoms.

Right arm went limp and she Right arm went limp and she couldn’t speakcouldn’t speak

Before ACA: Before ACA: No medical No medical homehome

Head CT was interpreted as normalHead CT was interpreted as normal She was diagnosed with TIA (transient She was diagnosed with TIA (transient

ischemic attack), hypertension, diabetes ischemic attack), hypertension, diabetes and discharged from the hospital ---and and discharged from the hospital ---and told to follow-up with her told to follow-up with her primary care primary care doctordoctor

Being your average divorced mom and Being your average divorced mom and working full-time to make ends meet; she working full-time to make ends meet; she had no health insurancehad no health insurance much less a much less a primary care doctorprimary care doctor. .

Before ACA: fragmented Before ACA: fragmented carecare

At the clinic she was tearful. Adela At the clinic she was tearful. Adela had been referred to physical had been referred to physical therapy for therapy for arm painarm pain and had been and had been scheduled a pap smear at my clinic.scheduled a pap smear at my clinic.

“ “But what is wrong with my arm?” But what is wrong with my arm?” ER report reads “transient ischemic ER report reads “transient ischemic

attack” which implies that the attack attack” which implies that the attack was temporary or resolved was temporary or resolved

But in the clinic Adela’s speech is slurred But in the clinic Adela’s speech is slurred

as if she’s intoxicated. Her daughter who as if she’s intoxicated. Her daughter who accompanied her adds “she doesn’t usually accompanied her adds “she doesn’t usually sound like that” Adela nods frustrated. sound like that” Adela nods frustrated.

Today’s Physical Exam (Prevention) reveals Today’s Physical Exam (Prevention) reveals there is a problem with her balance and there is a problem with her balance and coordination. coordination.

Likely she has had a small stroke often Likely she has had a small stroke often hard to find on CT scans.hard to find on CT scans.

Fragmented CareFragmented Care

Adela is confused, “I’ve been healthy Adela is confused, “I’ve been healthy for all these years…” for all these years…”

Adela’s last visit with a doctor was Adela’s last visit with a doctor was four years ago for a pap smear only. four years ago for a pap smear only. (free for all low income women (free for all low income women under the BCDP program)under the BCDP program)

Weeks later, an MRI of her head Weeks later, an MRI of her head confirms the diagnosis: Brainstem confirms the diagnosis: Brainstem stroke!stroke!

An ounce of prevention An ounce of prevention worth a pound of cureworth a pound of cure

Hypertension: the “silent killer”Hypertension: the “silent killer” High Cholesterol: You can’t feel it High Cholesterol: You can’t feel it

until it’s already done damageuntil it’s already done damage Diabetes: no symptoms until advancedDiabetes: no symptoms until advanced All easily diagnosed with routine visit All easily diagnosed with routine visit

and labsand labs Adela is a tragic example of why we Adela is a tragic example of why we

need ACA need ACA

Without Health Reform Without Health Reform LAWLAW

14% of Hispanics have 14% of Hispanics have been diagnosed with been diagnosed with Diabetes compared to Diabetes compared to 8% whites8% whites

Many with diabetes Many with diabetes remain undiagnosed remain undiagnosed especially those especially those without without access to health careaccess to health careIf current trends continue 1 in every 2 minoritychildren born today will develop type 2 DM at some point in their lives!Center for American Progress “Easing the Burden 2010”

A new dawn…life after A new dawn…life after ACAACA

2010 Insurance Reforms2010 Insurance Reforms

Establish a temporary national high-Establish a temporary national high-risk pool to provide health coverage to risk pool to provide health coverage to individuals with pre-existing medical individuals with pre-existing medical conditions. (Effective 90 days following conditions. (Effective 90 days following enactment until January 1, 2014)enactment until January 1, 2014)

Adela: with stroke, DM, HTN, Chol, Adela: with stroke, DM, HTN, Chol, and limited choices can join the Hi and limited choices can join the Hi Risk Pool in California nowRisk Pool in California now

2010 Insurance Reform2010 Insurance Reform

Require qualified health plans to provide at Require qualified health plans to provide at a minimum a minimum coverage without cost-sharing coverage without cost-sharing for preventive services, recommended for preventive services, recommended immunizations, preventive care for infants, immunizations, preventive care for infants, children, and adolescents, and additionalchildren, and adolescents, and additional

preventive care and screenings for women.preventive care and screenings for women. Adela’s PAP, mammogram, physicals, Adela’s PAP, mammogram, physicals,

approved disease screening is INCLUDED approved disease screening is INCLUDED with her insurance, not extra!with her insurance, not extra!

Adela would get regular complete Adela would get regular complete physicals plus mammograms. physicals plus mammograms.

Her primary doctor would notice her Her primary doctor would notice her elevated blood pressure and screen her elevated blood pressure and screen her for diabetes and cholesterol when she for diabetes and cholesterol when she was 35. They would find her cholesterol was 35. They would find her cholesterol and blood sugar too high. and blood sugar too high.

Her primary doctor would start 3 simple Her primary doctor would start 3 simple medications. medications.

Adela never suffers a preventable stroke! Adela never suffers a preventable stroke!

2011 Medicare Changes2011 Medicare Changes Improve access to care by increasing funding by Improve access to care by increasing funding by

$11 billion for community health centers and by $11 billion for community health centers and by $1.5 billion for the National Health Service Corp$1.5 billion for the National Health Service Corp

Provide a 10% Medicare bonus payment to Provide a 10% Medicare bonus payment to primary care physicians, and to general primary care physicians, and to general surgeons practicing in health professional surgeons practicing in health professional shortage areas. shortage areas.

Adela chooses a clinic in her rural town, there Adela chooses a clinic in her rural town, there are plenty of doctors and she gets an are plenty of doctors and she gets an appointment when she needs it, NOT 3 appointment when she needs it, NOT 3 MONTHS later!!MONTHS later!!

2014 State-Based Health 2014 State-Based Health ExchangeExchange

Create state-based Health Create state-based Health Exchanges through which Exchanges through which individuals and small individuals and small businesses with up to 100 businesses with up to 100 employees can purchase employees can purchase qualified coverage.qualified coverage.

As a fulltime worker whose As a fulltime worker whose job doesn’t offer health job doesn’t offer health insurance. Adela shops for insurance. Adela shops for insurance in her states insurance in her states “health exchange”.“health exchange”.

2014 ACA: Reduces out-of-pocket 2014 ACA: Reduces out-of-pocket limits for those with incomes up to limits for those with incomes up to

400% FPL400% FPL

100-200% FPL: $1,983/individual 100-200% FPL: $1,983/individual $3,967/family in 2010 $3,967/family in 2010

200-300% FPL: $2,975/individual200-300% FPL: $2,975/individual

$5,950/family in 2010);$5,950/family in 2010); 300-400% FPL: $3,987/individual 300-400% FPL: $3,987/individual

$7,973/family in $7,973/family in 2010)2010)

Adela can afford to purchase insurance.Adela can afford to purchase insurance.

2014 Insurance Reform2014 Insurance ReformRequire guarantee issue and Require guarantee issue and renewability and allow rating renewability and allow rating variation based only onvariation based only on Age Age Premium rating areaPremium rating area family compositionfamily composition and tobacco use and tobacco use

2014 NO ANNUAL LIMITS OF 2014 NO ANNUAL LIMITS OF COVERAGECOVERAGE

Adela can not be dropped from her plan Adela can not be dropped from her plan or have her premium skyrocket for or have her premium skyrocket for having diabetes or a stroke!having diabetes or a stroke!

What about the What about the undocumented?undocumented?

Reform Law: does Reform Law: does notnot cover the cover the undocumentedundocumented

Only emergency Only emergency (Medi-Cal)(Medi-Cal)

Many counties Many counties don’t cover don’t cover undocumented in undocumented in indigent programsindigent programs

CHECK YOUR CALIFORNIA COUNTY AT CHCF WEBSITE:ww.chcf.org/publications/2009/10/county-programs-for-the-medically-indigent-in-california

Mexican ImmigrantsMexican Immigrants

Over 2/3 of Mexican immigrants Over 2/3 of Mexican immigrants working in jobs that are heavily reliant working in jobs that are heavily reliant on Mexican immigrants have on Mexican immigrants have no no medical insurance coveragemedical insurance coverage

Only 5% of employed Mexican Only 5% of employed Mexican immigrants are covered by Medicaid immigrants are covered by Medicaid and other public insuranceand other public insurance

www.healthpolicy.ucla.edu/pubs/files/www.healthpolicy.ucla.edu/pubs/files/immigration_rep_Oct07.pdfimmigration_rep_Oct07.pdf

California has the largest California has the largest population of population of

Migrant/Seasonal Farm Migrant/Seasonal Farm workersworkers

1990 CA 1,362,534 TX 500,138 FL 1990 CA 1,362,534 TX 500,138 FL 435,373435,373

2000 CA 1,302,797 TX 362,724 FL 2000 CA 1,302,797 TX 362,724 FL 286,725286,725

1990 Atlas of Migrant and Seasonal Farm workers 1990 Atlas of Migrant and Seasonal Farm workers NCFWNCFW

2000 Farm worker Enumeration Study NCFW2000 Farm worker Enumeration Study NCFW

Farm work Farm work accounts for 13% accounts for 13% of allof all

workplace workplace fatalities, making fatalities, making it one of theit one of the

most dangerous most dangerous occupations in occupations in the U.S.the U.S.

http://www.healthpolicy.ucla.edu/pubs/files/immigration_rep_oct07.pdf

Where do the undocumented Where do the undocumented receive care?receive care?

Safety Net ProvidersSafety Net Providers Public/ Non-Profit HospitalsPublic/ Non-Profit Hospitals Community Health Centers (41%) non-Community Health Centers (41%) non-

citizen, non-legal permanent resident citizen, non-legal permanent resident Hispanics state that their usual provider is Hispanics state that their usual provider is a community clinic or health center. (US a community clinic or health center. (US DHHS 2008) DHHS 2008)

County ClinicsCounty Clinics Sliding Scale, Fee for Service, Family Pact, Sliding Scale, Fee for Service, Family Pact,

BCDP (limited scope)BCDP (limited scope)

Safety Net: Community Safety Net: Community ClinicsClinics

2008:2008:

78% of primary care visits at 78% of primary care visits at community community clinics clinics were made by were made by safety netsafety net patients patients

(56% Medi-Cal or Healthy Families)(56% Medi-Cal or Healthy Families)

(22% by uninsured/indigent) (22% by uninsured/indigent)

6% Private Insurance6% Private Insurance

California Healthcare Foundation Safety Net Facts and Figures 10/2010California Healthcare Foundation Safety Net Facts and Figures 10/2010

ACA and LatinosACA and Latinos

Funding to establish more Community Funding to establish more Community Health Centers (where uninsured go Health Centers (where uninsured go for care)for care)

Funding to National Health Service Funding to National Health Service Corp (more docs practice in shortage Corp (more docs practice in shortage areas)areas)

Funding for Teaching health centers: Funding for Teaching health centers: Primary care residencies in community Primary care residencies in community based clinics (more clinic docs trained)based clinics (more clinic docs trained)

Easing the Burden: Center for American Progress December 2010

ACA and LatinosACA and Latinos Initiatives to increase health workforce Initiatives to increase health workforce

diversity: scholarships/assistance to diversity: scholarships/assistance to disadvantaged students who commit to work disadvantaged students who commit to work with underservedwith underserved

Grants to states, hospitals, public health Grants to states, hospitals, public health depts, clinics to promote to use of community depts, clinics to promote to use of community health workers in medically underserved health workers in medically underserved areas (peer outreach)areas (peer outreach)

Support for development of cultural Support for development of cultural competency curriculum in health professional competency curriculum in health professional schoolsschoolsEasing the Burden: Center for American Progress December 2010

ReferencesReferences A Day in the Life of the UninsuredA Day in the Life of the Uninsured: California Academy of Family : California Academy of Family

Physicians Magazine October 2008 Physicians Magazine October 2008 KFF Health Reform TimelineKFF Health Reform Timeline: www.kff.org/healthreform/8060.cfm: www.kff.org/healthreform/8060.cfm Easing the BurdenEasing the Burden Center for American Progress Center for American Progress

www.americanprogress.org/issues/2010/12/easing_the_burden.htmwww.americanprogress.org/issues/2010/12/easing_the_burden.htmll

Migration Health And Work Facts Behind the MythsMigration Health And Work Facts Behind the Myths: :

October 15, 2007 - University of California, et al HIAOctober 15, 2007 - University of California, et al HIA California Health Care Foundation: California Health Care Foundation:

Safety Net Facts and Figures October 2010Safety Net Facts and Figures October 2010 National Center For Farm worker Health: National Center For Farm worker Health: www.ncfh.org

DemographicsDemographics U.S. DHHS Health Centers Americas Primary Care Safety Net U.S. DHHS Health Centers Americas Primary Care Safety Net

www.hrsa.gov/bphc/HRSA_HealthCenterProgramReport.pdfwww.hrsa.gov/bphc/HRSA_HealthCenterProgramReport.pdf