Engaging AAPIs in Ohio

The Patient Protection & Affordable Care Act (PPACA)

andThe Ohio Health Insurance

Exchange/SHOP

Objectives1. Describe problems in the current health care system

2. Explain ACA improvements to the current health care system

3. Explain the Health Insurance Exchange/SHOPo Potential benefitso Points of advocacy

…for AAPIs in Ohio, and4. Address the impact of Issue 3 on the ACA and

Exchange/SHOP in Ohio

AAPI Employment Issues

National data show that Southeast Asians and NHPIs especially suffer from:

• Low earnings• High poverty rates• High unemployment rates

Specifically the Vietnamese, Cambodian, Hmong, Lao, and NHPI ethnic groups

AAPI Employment IssuesMedian Family Income

Median Income per Person

Poverty Rate (all families)

Unemployment rate

White, non-Hispanic

69,636 31,735 6.3 6.2

Asians, all 79,145 30,055 8.1 5.9

Vietnamese 59,129 22,263 12.1 6.6

Cambodian 49,226 16,913 13.9 9.6

Hmong 49,918 11,030 24.7 11.5

Native Hawaiian / Pacific Islander

60,515 20,286 12.9 9.9

Poverty rates all above 10%

And in 2011, AAPIs as a whole had the highest long-term unemployment rate of any ethnic group: over half were unemployed for over 6 months.

Source: Kim, Marlene. 2011. “Asian Americans and Pacific Islanders: Employment Issues in the United States.” AAPI Nexus 9(1-2)

The State of AAPI Business

National data show that AAPI-owned businesses:

• Are clustered in low-paying industries (retail, restaurants, personal services)

• Employ fewer workers on average than white-owned businesses.

• Report much lower average receipts than white-owned businesses

The State of AAPI Business

Firms with Employees

% Employer Firms Average Sales/Receipts

Average Number of Employees

White, non-Hispanic 21.5% $2,082,036 11.5

Latino 11% $1,124,848 7.7

Black / African-American

5.5% $911,594 8.5

Asian 25.6% $1,141,280 7.1

Native Hawaiian / Pacific Islander

11% $1,264,828 9.1

Native American 10% $1,161,951 7.8

55%

60%

Source: Tran, Diem Linda and OiYan A. Poon. 2011. “The State of Asian American Businesses.” AAPI Nexus 9(1-2)

Most AAPI businesses see lower revenue and have a small number of employees

Objectives1. Describe problems in the current health care system

2. Explain ACA improvements to the current health care system

3. Explain the Health Insurance Exchange/SHOPo Potential benefitso Points of advocacy

…for AAPIs in Ohio, and4. Address the impact of Issue 3 on the ACA and

Exchange/SHOP in Ohio

Problems in Health Care Today for AAPIs

Vulnerable AAPIs ‘slip through the cracks’ of the health care system due to:

Lack of insurance

Underinsurance

Health disparities

Health Care Problems for AAPIs

Many AAPIs Cannot Afford Insurance

Employer-sponsored insurance Over half of all unemployed AAPIs remained so for over 6 months in

2011, an increase from 2010.

 Expensive small group and individual plans High poverty rates among Southeast Asians and NHPIs.

• Many low-income AAPI individuals cannot afford private health insurance Asian-owned businesses clustered in low-earning industries.

• Low-end AAPI firms cannot afford to purchase insurance for employees

 No Medicaid• No coverage for most adults: only children and their parents,

pregnant women, and people with disabilities• Legal permanent residents are ineligible for Medicaid in Ohio.

Health Care Problems for AAPIs

Many AAPIs Are Denied InsurancePre-existing conditions• Insurers can still deny coverage to people who come to

them with a medical condition• AAPIs in greatest need of health insurance are denied it

'Dropping‘ Asian Indians, Filipinas, and NHPIs, have high risk and

rates of developing Type II diabetes. • Before the PPACA was passed, insurers could 'drop' an

enrollee who became sick• AAPIs in greatest need of health insurance ended up

losing it

Many AAPIs Are Underinsured

Inadequate small group & individual plans Asian-owned firms tend to be smaller in size and revenue. High unemployment and poverty rates among Southeast Asians and

NHPIs.

• Low-income AAPIs individuals and businesses can only afford cheaper private health plans: minimal benefits, high deductibles, and other unfavorable terms

• AAPIs with pre-existing conditions may only qualify for such health plans High risk and rates of Type II diabetes among Asian Indians, Filipinas,

and NHPIs.

Many AAPIs Suffer from Health Disparities

Inadequate multilingual support• Example: Ohio Medicaid website has only Somali support• Limited English-proficient AAPIs cannot make informed

decisions about their health plans

 Inadequate data collection• Federal agencies currently collect health data on minority

populations in overly broad racial categories ('Asian', 'Hispanic')

• Health care providers remain ignorant of AAPI health needs E.g. Type II diabetes, domestic violence, and mental illness

among AAPIs ASIA was recently denied funding to start an HIV screening

program “specifically because APIs are not considered to be at risk for HIV”.

Objectives1. Describe problems in the current health care system

2. Explain ACA improvements to the current health care system

3. Explain the Health Insurance Exchange/SHOPo Potential benefitso Points of advocacy

…for AAPIs in Ohio, and4. Address the impact of Issue 3 on the ACA and

Exchange/SHOP in Ohio

The ACA Can Improve Health Care for AAPIs

The ACA contains provisions to make health care 

more affordablemore accessible

and more fair to consumers Implemented correctly, these provisions can combat 

Lack of insuranceUnderinsurance

Health disparities

How the ACA Improves Health Care for AAPIs

The ACA is being implemented in two phases:

2014Phase 2Phase 1

Today

In effect today

No more pre-existing condition denial for children

In effect today

Insurance coverage for dependents up to age 26

In effect today

Seniors on Medicare receive drug rebate checks

How the ACA Improves Health Care for AAPIs

RIGHT NOW!

Asian Indians, Filipinas, and NHPIs have high risk and rates of developing Type II diabetes

In effect today

No more ‘dropping’In effect today

FREE preventive health care for adults

• The ACA requires new health plans to make all adult preventive services FREE

• Examples: diabetes screening, some vaccines, Pap smears, prostate cancer screening

How the ACA Improves Health Care for AAPIs

RIGHT NOW!

In effect today

Most AAPI businesses qualify for tax credits to provide insurance

• Tax credit: up to 35% of employer’s insurance cost• For employers with 25 or fewer full-time employees and

average annual wages of less than $50,000 Remember: Asian and NHPI firms employ an average of

7 and 9 employees, respectively.

How the ACA Improves Health Care for AAPIs

RIGHT NOW!

How the ACA Will Improve AAPI Health CarePhase 1Today

March 2012

Improved data collection to reduce health disparities

Additional racial and ethnic categories for reporting on Asian, Hispanic/Latino, and Pacific Islander populations (March 23, 2012)

2014

January 1, 2014

[The individual mandate]

How the ACA Will Improve AAPI Health CarePhase 22014

All citizens and legal residents must enroll in a health plan or pay a tax penalty

EXEMPTIONS• Undocumented immigrants• Financial hardship• Lowest cost plan > 8% individual

income• Incomes below tax filing threshold• Religions objections• Without coverage less than 3

months

High poverty rates & low earnings for Southeast Asians and NHPIs

Economically vulnerable AAPIs will be exempt.

January 1, 2014

[The employer mandate]

• Employers with over 50 full-time workers must offer health insurance to their employees or pay a tax penalty.

Asian and NHPI firms employ an average of 7 and 9 employees, respectively

• Most AAPI-owned businesses will be exempt from the penalty but eligible for tax credits to provide employee insurance.

How the ACA Will Improve AAPI Health CarePhase 22014

January 1, 2014

Most AAPI businesses will qualify for even higher tax credits to provide insurance

• Phase 2 tax credit: up to 50% of employer’s insurance cost for two years

• 25 full-time employees or <$50,000 average annual wages

January 1, 2014

Expanded Medicaid coverage• Medicaid will be expanded to all citizens under age 65 with incomes up

to 133% of the federal poverty level Will especially benefit naturalized citizens from AAPI groups

marked by 10%+ poverty rates• Legal permanent residents still unlikely to be eligible in Ohio

How the ACA Will Improve AAPI Health CarePhase 22014

January 1, 2014

No more refusal for pre-existing conditions Especially beneficial to AAPI populations at risk for Type II

diabetes, obesity, mental illness, and chronic conditions• Health insurers will be prohibited from refusing health

coverage due to a pre-existing condition

June 2012!

Establish State insurance Exchange and SHOPs

How the ACA Will Improve AAPI Health CarePhase 22014

Objectives1. Describe problems in the current health care system

2. Explain ACA improvements to the current health care system

3. Explain the Health Insurance Exchange/SHOPo Potential benefitso Points of advocacy

…for AAPIs in Ohio, and4. Address the impact of Issue 3 on the ACA and

Exchange/SHOP in Ohio

The Ohio Health Insurance Exchange & SHOP

1. What are the Exchange & SHOP*?

2. Benefits of an Exchange & SHOP for AAPI Ohioans

3. Making the Exchange & SHOP Work for AAPIs

*Small Business Health Options Program

The Ohio Health Insurance Exchange & SHOP

The Exchange & SHOP will be “insurance supermarkets” for individuals and small businesses, respectively.

They will have an easy-to-use website for comparison shopping of multiple health plans.

The PPACA calls on each state to pass legislation establishing an Exchange/SHOP by June 2012.

Benefits of an Exchange & SHOP

If designed and operated ideally, the Exchange & SHOP would offer AAPIs greater and fairer access to health insurance through:

Affordability

Transparency

QualityAn Essential Health Benefits package in every plan sold

in the Exchange/SHOP (Qualified Health Plan)

Consumer advocacy and guidanceNavigators from the communities they serve.

Benefits of an Exchange & SHOP

AffordabilityLower premiums, higher

discounts

Exchange & SHOP will also monitor premium increases

Bargaining power of many individuals and small businesses

Benefits of an Exchange & SHOP

AffordabilityTax credits to help buy insurance for middle-class consumers

[family of 4 earning up to $90,000 in 2011]

Co-pay & deductible assistance for eligible consumers. Although unlikely to be eligible for Medicaid, legal permanent

residents WILL QUALIY FOR TAX CREDITS to buy insurance in the Exchange

Would especially benefit low-income AAPI groups (Southeast Asians & NHPIs)

Tax credits for small employers to help buy insuranceIncrease from 35% to 50% of insurance costs in 2014

Again, majority of AAPI-owned firms will qualify due to low numbers of employees

Benefits of an Exchange & SHOP

TransparencyEasy comparison of health plans for consumers

• Easy-to-understand, standardized language describing costs and benefits of all Qualified Health Plans (QHPs)

• Easy-to-use website built for comparison shopping

Benefits of an Exchange & SHOP

QualityEssential Health Benefits package: every QHP sold in the

Exchange/SHOP, regardless of price, will cover a standard set of benefits from 10 benefit categories.

1. ambulatory patient services

2. emergency services3. hospitalization4. maternity and newborn

care5. mental health and

substance use disorder services*

6. prescription drugs

1. rehabilitative and habilitative services and devices

2. laboratory services3. preventive and

wellness services and chronic disease management*

4. pediatric services, including oral and vision care.

Benefits of an Exchange & SHOP

Consumer Advocacy & Guidance

The Exchange/SHOP will regulate participating insurers

• Prohibit unethical advertising• Monitor and review premium increases

Designated or certified “Navigators”• Non-profit, third-party organizations • Help consumers find, understand and enroll in the

Exchange health plan which best suits their needs

1. Describe problems in the current health care system

2. Explain ACA improvements to the current health care system

3. Explain the Health Insurance Exchange/SHOPo Potential benefitso Points of advocacy

…for AAPIs in Ohio, and4. Address the impact of Issue 3 on the ACA and

Exchange/SHOP in Ohio

Objectives

Exchange & Shop

Making it Work for AAPIsTo maximally empower AAPIs, and all health care consumers, the Exchange & SHOP should be designed and operated along these principles:

Run by Ohio

Pro-consumer governing board

Multilingual access

Effective regulation

Exchange & SHOP: Making It Work for AAPIs

Run by Ohio

Ohio should establish and operate the Exchange/SHOP• Avoid defaulting to a federal-level Exchange/SHOP

unlikely to meet the needs of diverse AAPI groups in Ohio.

Including but not limited to the Burmese, Bhutanese, Hmong, Mon, Karen, and Nepalese refugee communities.

Exchange & SHOP: Making It Work for AAPIs

Pro-Consumer Governing BoardThe board that designs and oversees the Exchange &

SHOP must include

Consumer, labor, and small business representatives alongside industry experts.

An AAPI health expert among other minority health experts.

A strong conflict of interest clause that excludes those with financial interests in health care.

HospitalsPhysiciansInsurersBrokers

…and any individuals or organizations who may profit from enrollment in a health plan

Exchange & SHOP: Making It Work for AAPIs

Multilingual AccessThe Exchange & SHOP should be accessible to limited

English proficient communities:

Exchange website should have AAPI language support

Navigators for AAPI ethnic groups• Based in the communities they serve• Ethnically diverse• Culturally and linguistically competent

Exchange & SHOP: Making It Work for AAPIs

Effective Regulation

Ensure quality health plans in the Exchange & SHOP• The Exchange/SHOP should be able to accept or reject health plans

for sale based on price and quality Advocacy example: to be sold in the Exchange, a health plan

must help reduce health disparities by offering customer service in AAPI languages and covering prevention, treatment, and management of common AAPI conditions

Bad example: Utah’s Exchange must accept all health plans

Massachusetts: allows its Exchange to select bidding health insurers based on quality and value.

1. Describe problems in the current health care system

2. Explain ACA improvements to the current health care system

3. Explain the Health Insurance Exchange/SHOPo Potential benefitso Points of advocacy

…for AAPIs in Ohio, and4. Address the impact of Issue 3 on the ACA and

Exchange/SHOP in Ohio

Objectives

What about Issue 3?New Ohio Constitution Section 21A: No federal, state, or local law or rule shall compel, directly or indirectly, any person, employer, or health care provider to participate in a health care system.

This section was written to prevent the ACA's individual responsibility requirement from applying in Ohio. However:

Participation in the Exchange & SHOP is voluntary  • Individuals and employers are not required to purchase from the

Exchange or SHOP• Insurance companies are not required to sell plans in the Exchange

or SHOP

The Supreme Court is reviewing the constitutionality of the ACA.

Under the federal supremacy clause, federal law trumps state law

What about Issue 3?

Pending the Supreme Court’s decision, the ACA is the law of the land.

Issue 3 has no bearing on the establishment of an Ohio Exchange & SHOP.

Key Takeaways1. The Affordable Care Act extends greater consumer

protections to all Ohioans.

2. The ACA makes health insurance more affordable for economically vulnerable AAPI groups.

3. The ACA makes health insurance more affordable for AAPI business owners.

4. The Exchange & SHOP give all Ohioans greater control over their health care (easy-to-use, comparison shopping website).

5. The Exchange & SHOP can be designed to benefit AAPI health interests.

Sources

• “Asian Americans continued to suffer the most from long-term unemployment in 2011” (Economic Policy Institute) : http://www.epi.org/publication/ib323s-asian-american-unemployment-update/

• “Better Health Insurance Options for Ohio” (Ohio Consumers for Health Coverage”

• “Essential Health Benefits Bulletin” (Center for Consumer Information and Insurance Oversight) Dec. 16, 2011

• “Exchanges: Top Ten Priorities for Consumer Advocates” (Community Catalyst)

• “Summary of Coverage Provisions in the Patient Protection and Affordable Care Act” (Kaiser Family Foundation)

• “Summary of New Health Reform Law” (Kaiser Family Foundation”

• “Why We Need a Health Insurance Exchange” (Families USA)

• http://erc.msh.org/provider/informatic/AAPI_Diabetes_Incidence.pdf

• “The Health Care Law and You: What’s Changing and When”: http://www.healthcare.gov/law/timeline/