end structural inequities

Tag: disparities (Page 1 of 2)

In the absence of legislation around immigration reform, Barack Obama used executive actions to create policy, i.e. now we have DACA. Taking a similar page out of the presidential playbook, Donald Trump is using executive orders to bring about a retrenchment from the Affordable Care Act.

Today there was not one, but two, EOs that will increase uncertainty in the health insurance marketplaces, such as Covered California.

  1. Association Health Plans and Short-term Insurance: AHPs are plans for small businesses (and maybe self-employed individuals) who band together. Both AHPs and short-term plans can lead to a broader range of cheaper insurance options- in part because neither one has to meet ACA or state requirements, e.g. these plans do not have to cover essential health benefits such as prescription drugs (required for the marketplace plans). Healthy people who don’t need comprehensive coverage will be drawn to the cheaper AHPs and short-term plans, leaving behind sicker people in the marketplaces. The more sick people are packed into the marketplace, the higher premiums will go.
  2. Cost-sharing subsidies: These are payments that the federal government makes to help cover the costs of co-payments, deductibles, etc., for low-income people buying insurance in the marketplaces (over half of buyers).  Without the subsidies, health insurance plans will (and have already, due to uncertainty) increased premiums.

Both EOs could also make the cost of doing business in the marketplaces too high, and insurance plans may simply drop out.

*Now both EOs are likely to trigger lawsuits from states (1) and insurance companies (2) so it’s likely not much will happen yet. (2) can also be resolved by an act of Congress.

However, Congress has not yet renewed funding for the Children’s Health Insurance Program, employers are not required to offer plans with contraceptive coverage, and Puerto Rico–still struggling for clean drinking water and electricity– is on a Medicaid block grant.

I try to conclude these posts with a summary for implications for disparities- but they all seem to come to the same conclusion: if these EOs come to pass in the absence of other reforms, disparities by income, race and ethnicity, and gender, are all likely to widen. For all the new choices available, those with chronic and pre-existing conditions will likely see their premiums go up.




Both BCRA and AHCA would allow states to receive Medicaid funds in the form of a block grant- this would enable states to construct their programs and funding to fit the needs and priorities of their residents, rather than be subject to inflexible federal rules that may make no sense across different contexts.

Sounds good, right? Not so fast. On the Health Affairs blog, Prof. Marianne Bitler and I argue that the history of welfare reform shows it may not be that easy.

How many acronyms were up there? (A few) Senate Republicans released their draft response to the House American Health Care Act, the Better Care Reconciliation Act.  There is much more detail in BCRA, and yet the upshot seems to be that BCRA ups the ante from the AHCA on disparities, again favoring the younger, healthier and wealthier vs. the poorer, sicker, and older.

Others have written excellent summaries of the BCRA overall, as well as specific review of changes to Medicaid not related to caps,  So I won’t waste your time or mine.

A couple points-

  1. Immigrants: There’s a small distinction which appears to restrict premium tax credits from a subset of immigrants, all of whom are Lawfully Present (allowed to stay in US)  but now limited to Qualified Aliens vs. Non-Qualified Aliens.  As a non-expert, Non-qualified is utterly confusing to me and all I have figured out so far is that those under DACA are Non-Qualified and therefore would not be eligible for tax credits to purchase health insurance.
  2. Elimination of the ACA Public Health and Prevention Fund: once again signaling how the U.S. simply does not prioritize public health.
  3. Tax cuts for the wealthy: Income inequality goes up–> Health disparities go up.
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