Engaging AAPIs in Ohio

1. Engaging AAPIs in Ohio The Patient Protection & Affordable Care Act (PPACA) andThe Ohio Health Insurance Exchange/SHOP

2. Objectives • Describe problems in the current health care system • Explain ACA improvements to the current health care system • Explain the Health Insurance Exchange/SHOP • Potential benefits • Points of advocacy • …for AAPIs in Ohio, and • Address the impact of Issue 3 on the ACA and Exchange/SHOP in Ohio

3. 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

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

5. 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

6. The State of AAPI Business 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

7. Objectives • Describe problems in the current health care system • Explain ACA improvements to the current health care system • Explain the Health Insurance Exchange/SHOP • Potential benefits • Points of advocacy • …for AAPIs in Ohio, and • Address the impact of Issue 3 on the ACA and Exchange/SHOP in Ohio

8. 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

9. 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.

10. Health Care Problems for AAPIs Many AAPIs Are Denied Insurance Pre-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

11. 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.

12. 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”.

13. Objectives • Describe problems in the current health care system • Explain ACA improvements to the current health care system • Explain the Health Insurance Exchange/SHOP • Potential benefits • Points of advocacy • …for AAPIs in Ohio, and • Address the impact of Issue 3 on the ACA and Exchange/SHOP in Ohio

14. The ACA Can Improve Health Care for AAPIs The ACA contains provisions to make health care more affordable more accessible and more fair to consumers Implemented correctly, these provisions can combat Lack of insurance Underinsurance Health disparities

15. Today 2014 Phase 1 Phase 2 How the ACA Improves Health Care for AAPIs The ACA is being implemented in two phases:

16. How the ACA Improves Health Care for AAPIs RIGHT NOW! • 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

17. 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

18. 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.

19. Today Phase 1 How the ACA Will Improve AAPI Health Care 2014 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)

20. 2014 Phase 2 How the ACA Will Improve AAPI Health Care • January 1, 2014 [The individual mandate] 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.

21. 2014 Phase 2 How the ACA Will Improve AAPI Health Care • 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.

22. 2014 Phase 2 How the ACA Will Improve AAPI Health Care • 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

23. 2014 Phase 2 How the ACA Will Improve AAPI Health Care • 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

24. Objectives • Describe problems in the current health care system • Explain ACA improvements to the current health care system • Explain the Health Insurance Exchange/SHOP • Potential benefits • Points of advocacy • …for AAPIs in Ohio, and • Address the impact of Issue 3 on the ACA and Exchange/SHOP in Ohio

25. The Ohio Health Insurance Exchange & SHOP • What are the Exchange & SHOP*? • Benefits of an Exchange & SHOP for AAPI Ohioans • Making the Exchange & SHOP Work for AAPIs • *Small Business Health Options Program

26. 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.

27. 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 Quality An Essential Health Benefits package in every plan sold in the Exchange/SHOP (Qualified Health Plan) Consumer advocacy and guidance Navigators from the communities they serve.

28. Benefits of an Exchange & SHOPAffordability Lower premiums, higher discounts Bargaining power of many individuals and small businesses • Exchange & SHOP will also monitor premium increases

29. Benefits of an Exchange & SHOPAffordability Tax credits to help buy insurancefor 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 insurance • Increase from 35% to 50% of insurance costs in 2014 • Again, majority of AAPI-owned firms will qualify due to low numbers of employees

30. Benefits of an Exchange & SHOPTransparency Easy 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

31. Benefits of an Exchange & SHOPQuality Essential Health Benefits package: every QHP sold in the Exchange/SHOP, regardless of price, will cover a standard set of benefits from 10 benefit categories. • ambulatory patient services • emergency services • hospitalization • maternity and newborn care • mental health and substance use disorder services* • prescription drugs • rehabilitative and habilitative services and devices • laboratory services • preventive and wellness services and chronic disease management* • pediatric services, including oral and vision care.

32. Benefits of an Exchange & SHOPConsumer 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

33. Objectives • Describe problems in the current health care system • Explain ACA improvements to the current health care system • Explain the Health Insurance Exchange/SHOP • Potential benefits • Points of advocacy • …for AAPIs in Ohio, and • Address the impact of Issue 3 on the ACA and Exchange/SHOP in Ohio

34. Exchange & Shop Making it Work for AAPIs To 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

35. Exchange & SHOP: Making It Work for AAPIsRun 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.

36. …and any individuals or organizations who may profit from enrollment in a health plan Hospitals Physicians Insurers Brokers Exchange & SHOP: Making It Work for AAPIs Pro-Consumer Governing Board The 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.

37. Exchange & SHOP: Making It Work for AAPIs Multilingual Access The 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

38. Bad example: Utah’s Exchange must accept all health plans Massachusetts: allows its Exchange to select bidding health insurers based on quality and value. 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 andcovering prevention, treatment, and management of common AAPI conditions

39. Objectives • Describe problems in the current health care system • Explain ACA improvements to the current health care system • Explain the Health Insurance Exchange/SHOP • Potential benefits • Points of advocacy • …for AAPIs in Ohio, and • Address the impact of Issue 3 on the ACA and Exchange/SHOP in Ohio

40. 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

41. 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.

42. Key Takeaways • The Affordable Care Act extends greater consumer protections to all Ohioans. • The ACA makes health insurance more affordable for economically vulnerable AAPI groups. • The ACA makes health insurance more affordable for AAPI business owners. • The Exchange & SHOP give all Ohioans greater control over their health care (easy-to-use, comparison shopping website). • The Exchange & SHOPcan be designed to benefit AAPI health interests.

43. 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/