One year ago, the launch of the Affordable Care Act was so troubled and chaotic that the very survival of national health insurance reform seemed to be at risk. Now, despite the huffing and puffing of the likes of Senator Ted Cruz, the Affordable Care Act has been firmly ensconced in public policy, joining Medicare and Medicaid as the most significant changes in American social policy since FDR’s promulgation of Social Security.

Like the Affordable Care Act, Social Security had a troubled launch, albeit without the grandiosity of a web portal disaster like HealthCare.gov, and faced scathing attacks from the 1930s’ versions of the Koch brothers, but now just about no one would be so politically stupid to call for the repeal of Social Security.

Notwithstanding the likelihood of vainglorious attempts by some to call for repealing the Affordable Care Act, it is all but obvious that national health insurance reform has gained a permanent place in the nation’s array of social welfare policies. As Politico noted, even “the insurance industry believes Obamacare is here to stay no matter who wins control of the Senate this fall.” The impacts and indicators of success of the Affordable Care Act are visible and measurable:

Despite these and many other indicators of Affordable Care Act achievements and successes, there is much yet to be done to work through problems and shortcomings in the parts of the nation’s healthcare system. That’s where there are important roles for nonprofits, not just health-related nonprofits such as clinics and hospitals, but all nonprofits to ensure that the Affordable Care Act achieves what it can and should.


Navigating to Those Eligible who Remain Uninsured

Assume that when the next round of open enrollment for health insurance starts in November, HealthCare.gov will be working much better than it did a year ago. (It could hardly be worse.) Even those state exchanges that found themselves with troubled launches should be in general much improved. Given the technological obstacles that consumers faced in October of 2013, the achievements of the Affordable Care Act to date are attributable in many ways not to technology, but to human beings, particularly the people who functioned as “navigators” who helped consumers understand the options they faced on the exchanges and access services and subsidies they needed.

The Kaiser Family Foundation studied the work of the navigators and found that the various navigator or “assister” programs provided services to some 10.6 million people, about 90 percent of whom were uninsured when they reached out to navigators for help. Because of the complexity of the new law and the various problems with the federal and state exchange portals, providing assistance to consumers was not easy, often taking one or two hours per case. Navigators went to churches, homeless shelters, supermarkets, fairs, food banks, and other places to make themselves available to people who might need help in getting the health insurance coverage they deserved. Their achievements are a tremendous testament to the nonprofit sector, as most of the organizations that sponsored assister programs were nonprofit service organizations and nonprofit health centers:

  • Nonprofit service organizations – 38 percent
  • Federally qualified health centers (also nonprofit) – 28 percent
  • Hospitals/healthcare providers (many of which are nonprofit) – 15 percent
  • State/county/local government agencies – 8 percent
  • For-profit businesses – 3 percent
  • Faith-based organizations – 1 percent
  • Other – 7 percent

However, the millions of people the navigators reached in the first year might have been the easier targets. The remaining eligible uninsured may actually not know much about the Affordable Care Act and its individual mandate, may not understand much or anything about health insurance coverage, and may be apprehensive about dealing with issues of cost, taxes, and federal regulations.

For some navigator groups that just received new federal funding in preparation for the new enrollment period, their experiences the first year will give them a leg up on figuring out how to reach and how to help the uninsured in round two. However, the first year showed that the states with the greatest achievements in providing the uninsured with coverage were states with their own exchanges and states that had expanded Medicaid coverage. That means that the states that have historically had huge numbers of uninsured—for example, Texas, with 6 million uninsured—pose the biggest challenges. In Texas, like his predecessor Rick Perry, GOP gubernatorial candidate Greg Abbott, leading in the polls against Democrat Wendy Davis, has pledged to do all he can to prevent that state’s cooperation and compliance.

Reaching consumers who don’t know or are apprehensive about health insurance, and reaching consumers who happen to be in states where legislatures and governors are committed to last ditch opposition to social progress, will be a difficult obstacle for navigators to overcome.


Finding Coverage for Immigrants

It was one of the stupidest (another word maybe?) pieces of political pandering during the run-up to the congressional vote when Senate Democrats, led by Max Baucus (D-MT), pronounced undocumented immigrants ineligible for Affordable Care Act coverage. Perhaps they thought that kicking undocumented immigrants to the curb would soften right wing opposition to the legislation, but it didn’t. However, it did leave a large number of people without healthcare coverage, likely to crowd emergency rooms for non-emergency care or to go without health treatment at all.

Many of the pre-ACA uninsured were people of color, and the population group most likely to be uninsured was Latinos. Despite early reports to the contrary, the first year of the Affordable Care Act made substantial inroads into providing health insurance for previously uninsured Latinos. The Commonwealth Fund reported earlier this year that the rate of uninsured Latinos ages 19 to 64 fell from 36 percent in 2013 to 23 percent in 2014, and for uninsured young Latino adults ages 19 to 34, fell from 43 percent to 23 percent. Those achievements are particularly noteworthy, given that the two states with the largest number of potentially eligible Latinos—Florida and Texas—have not expanded Medicaid coverage nor done much of anything else to bring health insurance coverage to Latinos.

Thanks to Texas, Florida, and opponents of immigration more generally, Latinos still constitute the largest proportion of the nation’s uninsured, and among Latinos, the rates of uninsured people are higher for foreign-born Latinos and for non-citizen Latinos:

Percent without health insurance in 2014

  • U.S. overall – 14 percent
  • Hispanics overall – 25 percent
  • U.S.-born Hispanics – 17 percent
  • Foreign-born Hispanics – 39 percent
  • Foreign-born Hispanics, U.S. citizens – 21 percent
  • Foreign-born Hispanics, non-citizens – 49 percent

Whatever challenges there might be for eligible Latinos, the exclusion of undocumented immigrants from the Affordable Care Act “is a hole…in terms of coverage, that you can drive a truck through,” according to California Assembly member Rob Bonta. The ACA even prohibits coverage for beneficiaries of the Deferred Action for Childhood Arrivals (DACA) program, which gives temporary legal status to children of undocumented immigrants who came to the U.S. as children. But even for legal immigrants, there are challenges. For example, federal rules require a five-year waiting period for Medicaid coverage for legal immigrants, though states can opt to provide Medicaid coverage for children and pregnant women without the waiting period.

In the absence of congressional action on comprehensive immigration reform, there is no point to anticipating amendment of the Affordable Care Act to provide assistance to undocumented immigrants. Rather, like the legislation that Bonta and others like State Senator Ricardo Lara are promoting in California, the action to get undocumented immigrants covered will likely be in the states. For example, Connecticut enacted a law that established the Office of Health Equity, designed to eliminate disproportionately adverse health outcomes, including as a factor immigrant status. In Florida, there is pending legislation to provide Medicaid coverage to immigrant children, the bill sponsored by a Miami Republican state legislator.

This is an advocacy arena for the nonprofit sector—certainly at the national level, if there are possibilities of altering and improving the health insurance coverage of DACA program participants or more, but also at the state level. Nonprofits ought to be able to demonstrate quite persuasively that the taxpayer costs of sending undocumented immigrants to emergency rooms for charity care services are much higher than the cost of including undocumented immigrants in state health insurance programs.


Protecting Rural Americans

The purpose of the Affordable Care Act was not only to provide better health insurance coverage but to achieve better, fairer healthcare provision and health outcomes. It’s not happening for rural America. Reports indicate that many of the people who did not sign up for ACA coverage live in rural areas. Reaching out to and enrolling rural Americans is going to be one of the challenges in the next open enrollment period of the ACA.

According to the Kaiser Health News, one of the challenges is simple distance: “[Rural] residents have to travel farther to get face-to-face assistance from the so-called navigators and assisters hired to help consumers figure out the process. And Internet access is sometimes spotty, discouraging online enrollment.” In last year’s navigator grants, $2.5 million of the $66 million total was designated for rural outreach. For this year’s $60 million in navigators grants, whether there is a set-aside for rural is unclear. The rural challenge is exacerbated by the fact that many of the states that chose not to expand Medicaid coverage are in the South and Southwest, where there are large numbers of rural residents without health insurance coverage.

A national study of the unhealthiest counties in the nation revealed many to be rural counties, including Grundy County in Tennessee, Jackson County in Alabama, and Dade and Walker counties in Georgia. The challenges in rural areas include limited access to quality healthcare (and healthcare providers) and low incomes that make insurance premiums and deductibles difficult for many to afford even with subsidies. Because states such as Tennessee, North Carolina, and Georgia rejected Medicaid expansion and the federal subsidies that came with it, rural hospitals have been faced with difficult financial challenges that, unlike urban hospital systems with greater resources and economies of scale, have led to hospital closings and further diminution of access for rural communities.

Part of the challenge is a shortage of primary care doctors nationwide, but particularly in rural communities. As the Seattle Times explained, recruiting primary care doctors to rural areas is a challenge: “The work can be intimidating, with long hours and frequently being on call. It can be difficult for a physician’s spouse to find work in a place with limited economic opportunities. Finding a work-life balance is a struggle.”

Challenged by limited reimbursements and access to health care providers, rural hospitals and clinics are increasingly seen on lists of facilities being shut down. The National Rural Health Association reports that 14 rural hospitals shut down last year. Four of the 65 rural hospitals in Georgia have closed in the past two years, including Stewart-Webster, a critical-access hospital in Richland, Georgia, succumbing to the combined pressures of high rates of underinsured and uninsured rural residents and declining access to federal subsidies due to the state’s rejection of expanded Medicaid. In Bellhaven, North Carolina, the Vidant Pungo Hospital closed because of the state’s rejection of Medicaid expansion, and in a horrible story, a 48-year-old woman died of a heart attack while waiting for air transport to take her to the nearest remaining hospital—84 miles away.

The rural issue is one both of needed nonprofit advocacy and change in the health care system overall. When foundations write off rural areas as venues for advocacy, circumstances such as the multi-state rejection of Medicaid expansion occur, leaving institutions without the resources to adequately serve rural communities. But the issue is also one of human capital. For philanthropy, which invests heavily in teaching hospitals, the emphasis has to be refocused on the training of primary care doctors and nurses and mechanisms to attract them to service in rural areas.


The Nonprofit Advocacy Agenda for the ACA, Round 2

There is obviously much more to be done to strengthen and bolster the Affordable Care Act as a resource to achieve better health outcomes for Americans. For example, Ann Torregrossa of the Pennsylvania Health Funders Collaborative told the Nonprofit Quarterly in an email that because of mixed messages from the courts about whether federal assistance for consumers might be limited only to insurance purchased through the state exchanges, it is vital to get states such as Pennsylvania to apply for funding to operate a state insurance exchange, both subsidies for purchasers and federal grants for resources such as navigators. This is one of those issues that, had some in Congress not been so set on trying to undo the Affordable Care Act, would have led to a technical corrections bill to fix items like these that occurred due to drafting errors or analytical oversights. But Torregrossa’s note is an important reminder that nonprofits as implementers and nonprofits as advocates have to be smart about making the Affordable Care Act work. Nonprofits typically do that—taking programs from state and federal governments and figuring out how to make them practical and pragmatic, and how to avoid consequences that should have been rectified in the drafting process. That applies doubly to the Affordable Care Act.

One big issue advocated for by national nonprofit leadership groups was the availability of tax subsidies for nonprofits as small employers to maintain their provision of health insurance for their employees. It may be that for a number of reasons, many small nonprofit employers, like for-profit employers, do not qualify—perhaps because of the first year’s limitation to employers with 24 or fewer full-time employees with average incomes of less than $50,000, or the requirement that the employer pays at least half of the employees’ premiums, or that the tax incentive is only good for two consecutive years. It isn’t clear, but the utilization rate reported by both for-profit and nonprofit employers hasn’t been large. For the coming year, the definition of eligible employer increases to 49 or fewer employees, but the insurance involved must be purchased on state exchanges, not off-exchange. Nonprofit Quarterly has heard, without specifics, of a number of nonprofits dropping their employer-provided coverage and sending their employees to the insurance exchanges, in some cases with increases in their compensation to cover some of the lost payments that would have been ordinarily provided by the employer. Is this happening throughout the nonprofit sector? Is the tax subsidy that nonprofit leadership groups fought so hard to get deep enough to entice nonprofit employers to continue their role in providing health insurance? Are changes needed to help nonprofit employers and nonprofit employees obtain and maintain health insurance coverage?

As concerned as nonprofits might be about how they and their employees are faring under the Affordable Care Act, nonprofits should be promoting the nonprofit leaders who are bringing competition and quality to the otherwise oligopolistic insurance market. The nonprofit health insurance cooperatives signed up 400,000 people in the first year of the Affordable Care Act, a phenomenally impressive number for organizations that basically didn’t exist a year or two earlier. In some states, such as Kentucky, they surpassed the performance of mammoth competitors such as Anthem Blue Cross and Blue Shield. The successes of the insurance cooperatives have been reviewed repeatedly in Nonprofit Quarterly, including an article highlighting their branding and marketing initiatives, and will be the subject of an extensive feature article in the forthcoming issue of the print edition of the Quarterly.

This coming year, the consumer cooperative serving Maine, Maine Community Health Options, is making a rapid move to expand its offerings to neighboring New Hampshire, fueled by its surprising success in the first year of ACA open enrollment. The Kentucky Health Cooperative, which signed up 50 percent more people in the Bluegrass State than it had projected, is expanding into West Virginia as the West Virginia Health Cooperative. Montana’s co-op will be selling in Idaho.

These consumer health cooperatives were meant to be a replacement for the “public option” that the Obama administration abandoned in the face of Republican opposition during the congressional debate over the ACA legislation. Few expected them to do much, but increasingly, they have overcome legislatively mandated obstacles and not only survived as functioning insurance entities, but had exactly the competitive impact they were supposed to have against the bigger for-profit and mutual insurance providers that dominated the industry:

“A study from McKinsey & Co. noted that CO-OPs offered 37 percent of the lowest-priced plans in the states where they operate. According to NASHCO, states with a CO-OP had premium rates that were, on average, about nine percent lower than states without a CO-OP. The association says the findings indicate that the new competitors forced other carriers to lower rates.”

In this coming year, nonprofits might be well advised to support and promote the expanding legitimately nonprofit slice of the health insurance market, functioning as both important yardstick competition in the insurance industry and space for consumers and communities that want to free themselves from the negative impacts of control by big corporations.

Ultimately, the nonprofit challenge is one of advocating for health equity. Steve Lesky of Oregon’s Cambia Health Foundation sent Nonprofit Quarterly a note through Grantmakers of Oregon and Southwest Washington with a reminder of the ultimate purpose of the Affordable Care Act, predicting that this year and going forward, there would be—or should be—concentration on “what are the next best practices to achieving health equity: from community health workers to technology.” Health equity is the underlying challenge that should unite nonprofits of all stripes. Community-based and regional nonprofit advocates have just demonstrated that commitment to health equity with the opening this month of My Health L.A., a program for Los Angeles’ 400,000 to 700,000 estimated undocumented immigrants, matching them to clinics that will provide them with free primary care and health screenings, chronic disease management, prescription medications, and referrals to specialty care facilities and reimburse the clinics set amounts for each patient rather than reimbursing them by the number of patient visits (146,000 are expected to sign up). Mechanisms such as My Health L.A., working with community clinics, expanding access for populations previously deprived of coverage, and boosting quality healthcare provision should get the attention of nonprofits.

For the second year of the Affordable Care Act, the nonprofit sector has important roles to play: ensuring that the 15 million employees of nonprofits are adequately insured and receiving quality healthcare, advocating for the communities they serve to get the health coverage and healthcare provision they need and deserve, and strengthening the mechanisms of the Affordable Care Act so that it works as it should. That’s a health equity agenda that ought to involve nonprofit advocates, nonprofit service providers, and private foundations.