In a largely unexpected turn, the U.S. Supreme Court declared nearly the entire Affordable Care Act a constitutional and fully legal shift in the American health care system.
The court’s decision will be dissected today by legal scholars, health care experts, sharp-tonged commentators and ordinary Americans. But what may not be so widely discussed or understood is the sweeping effect that the court’s decision will likely have on minority health in the United States, according to health care economists and policy analysts. That broad benefit to minorities is a point the Obama administration itself has made -- though somewhat infrequently -- and one that's likely to be invoked more often after the favorable ruling, as the presidential election fight intensifies.
Black and Latino Americans are expected to see substantial gains in insurance coverage under the ACA. The bill was designed to offer the greatest assistance to those with low and moderate incomes. And with income, race and ethnicity still closely linked in the United States, just over 48 percent of the nearly 24 million people likely to gain health insurance as the law’s provisions are implemented across the country will be people of color, according to a May Urban Institute analysis.
But there are also nonpartisan, health-care oriented reasons to be less than jubilant about the ACA ruling. Most of the law does not take effect until 2014, including the mandate. As many as 26 million uninsured Americans are not expected to gain coverage, according to The Urban Institute analysis. And, the law will not immediately address other causes of minority health disparities, including the limited number of health care providers in poor communities and distrust of medical professionals.
Yet, yawning gaps in health insurance coverage between the nation’s white population and minorities have long been identified as root causes of lower life expectancy rates, more frequent complications from disease and more deaths from treatable conditions among minority groups. These disparities will be narrowed by the reforms enacted under ACA.
In 2010, Latinos under the age of 65 were nearly three times more likely to be uninsured, and black Americans nearly two times more likely to be uninsured, than white Americans of the same age, according to the May Urban Institute analysis. (After age 65 these health insurance coverage disparities nearly disappear because senior citizens are eligible for Medicare.)
“There are large, frankly huge, differences in health insurance coverage between segments of the American population,” Lisa Clemans-Cope, a health economist at The Urban Institute’s Health Policy Center, told HuffPost a day before the Supreme Court's ruling. “Consequentially there are huge differences in what the ACA could mean. We study this stuff and when we ran the numbers even we were shocked.”
Before the ACA, nearly 50 million Americans -- 20 percent of the population -- ranked as uninsured, said Clemans-Cope, who served as lead author of the Urban Institute's May study. Strictly speaking, the majority of these individuals are white. While the nation's demographics are changing swiftly, white Americans do make up most of the nation’s population. But, the study found a disproportionate share -- nearly 27 million of the uninsured -- were black, Latino or Asian.
The problem is most pronounced among Latinos. About 16 million Hispanics, nearly 33 percent of the Hispanic population, lacked health insurance in 2010, according to Census data.
Just over 7 million black Americans also did not have health insurance. That figure represents about 22 percent of the nation’s black population. By comparison, about 23 million white Americans -- nearly 14 percent of the white population -- numbered among the uninsured.
That matters because health insurance coverage is closely associated with better health. People who lack health insurance are far more likely to delay doctor’s visits, said Clemans-Cope. They are less likely to have serious health problems detected early and are less likely to receive preventative care or chronic disease treatment, and as a result, lead shorter lives.
“We know that health care access -- that is to say health insurance -- [has been] one of the primary drivers of actual racial health disparities for decades," Clemans-Cope said. “That’s what is at stake here.”
Put simply, under the nation’s health care law, subsidies will become available for individuals living in households that earn up to 400 percent of the federal poverty line. For a typical family of three, that figure is about $26,726. And, families earning up to 138 percent of the federal poverty line will be eligible for Medicaid. That’s families of three earning up to $21,724.
“There are a lot of numbers here so it may be hard to process," Clemans-Cope said. "But we’re talking about at least 25 percent of uninsured Latinos and 59 percent of uninsured African Americans becoming insured. That’s huge.”
For Latinos, the share that might gain health insurance under different aspects of the ACA is limited in part by questions of citizenship, the contents of the health care law and the timing of its implementation. Personal, geopolitical and economic forces shape how and when most people immigrate to the United States. Millions of Latinos have arrived in the last two decades. The wait to immigrate legally to the US can stretch more than 20 years for those who hail from countries subject to stricter U.S. immigration limits, such as Mexico.
The law leaves legal immigrants ineligible for all but health insurance subsidies during the first five years of their legal permanent residency status. Legal permanent residents are often described as people with green cards (although the actual card is pink), and such green card holders are eligible for the subsidies, but not subject to the individual mandate under the ACA.
The law offers no benefits -- no subsidy, no Medicaid eligibility -- to undocumented immigrants, and neither does it mandate that they purchase health insurance.
But millions of Latinos also live in mixed immigration status families, according to a 2010 Pew Hispanic Center analysis of U.S. births. In these families, some members are citizens, some are not. Some may be legal immigrants while others came to, or remained in, the United States without authorization. (The same is true about a smaller number of Asian, black and white families.)
This means that states will have to make strong efforts to clarify that taking advantage of subsidies will not lead to contact with immigration authorities.
“Really the impact of this whole thing, rides on what happens in two states,” Clemans-Cope said. “That’s Texas and California, because over half of all Latinos live there.”
Right now, both states have lower-than-average enrollment among those eligible for the children’s version of Medicaid, a government-financed insurance program, according to federal data. That suggests that neither state is doing a great job with outreach or education, Celmans-Cope said.
Another major determining factor in the effect of Thursday's decision is how states with large numbers of poor and moderate income residents -- but often politically conservative legislatures and governors -- respond to the federal government's call for greatly expanded Medicaid access, said Allison Hoffman, a lawyer and professor at the University of California Los Angles School of Law who specializes in health policy. The court ruled that the federal government does not have absolute authority in this area, the one quibble the court had with the ACA. The federal government will cover most of the initial costs.
Despite the indisputable disparities in health insurance coverage and overall health between the nation’s white, black and Latino populations, much of the discussion around the ACA has instead centered on questions of individual liberty and just how much of the country objects to the very notion of a health care mandate.
Many Americans thought this case boiled down to whether the government can force a person to buy health care (or veggies), Hoffman said.
“It may have something to do with the way that Americans respond to the word mandate,” she said. “But make no mistake, this was not a case about government intrusion or individual liberty. That’s not what the court considered here. This is a case that centers around the legal question of whether or not Congress has overstepped its Constitutional authority.”
The Affordable Care Act, despite its name, will also do little to alter the cost of care, Hoffman said. Several critics of the law have pointed to the fact that the Massachusetts reforms on which the policy is modeled dramatically increased access but did not do the same with costs.
That is the next and necessary frontier, Hoffman said.
The United States spends the most, per person, on health care in the world, Hoffman noted. But the United States does not even rank among the top 10 in several critical measures of health, including life expectancy.
“That’s mostly because unlike other developed countries, we have a large number of people who are uninsured,” Hoffman said. “Unfortunately, it’s the human cost of being uninsured that people just don’t seem to understand.”