The Congressional Budget Office this week downgraded its optimism that the president’s health reform law will work as planned next year. In its budget outlook, CBO foresaw trouble with the new insurance marketplaces, difficulty with Medicaid enrollment, and a limited suite of insurance options. In a sense, the report was no surprise: These sorts of technical challenges have dominated discussion of the law’s implementation—and the lives of many state and federal officials.
But even if the process is totally seamless, it may end up mattering little if the people without insurance fail to sign up for coverage. The health reform law’s dual goals of expanded and affordable coverage simply won’t work if a large proportion of those currently without insurance don’t participate. Hospitals and other providers are counting on a big reduction in uncompensated care to balance their books amid escalating payment cuts. And insurance risk pools will depend on enrolling young, healthy people to help offset the costs of the older and sicker Americans who will be most motivated to buy health coverage.
Activists and government officials looking to boost the rate of participation would be wise to start with the Latino community. Across the country, Latinos are insured in lower numbers than any other major ethnic population; about a third lack health coverage. And Hispanics have poor rates of participation in government health insurance programs. Although they are more likely than other groups to be enrolled in Medicaid or the Children’s Health Insurance Program, Latinos also have higher proportions of people who are eligible but not signed up. If health reform is going to succeed, it needs a good strategy for Latino enrollment.
“Sixty percent of the uninsured are Latino,” said Anthony Wright, executive director of Health Access California, a state with a large uninsured Latino population. “We need to figure this out for the whole enterprise to work.”
Many of the obstacles to Latino enrollment are common to the uninsured population in general. For one, only a fraction of those who will be eligible for new subsidies in 2014 have any idea they can get help in obtaining insurance. Polling done by Enroll America—a new group funded by health insurers, hospitals, and nonprofit organizations—has found that more than 80 percent of people who will become newly eligible for an expanded Medicaid program don’t know it. The numbers are only slightly better when it comes to people who will be able to collect tax credits to buy coverage in state marketplaces: 78 percent don’t realize the law will benefit them in this way.
Enroll America’s research shows that the numbers are even worse for Latinos—89 percent of those who could get benefits don’t know it. The No. 1 reason for this may be the same one that advocates cite for low Medicaid participation numbers: language barriers. Among Latino citizens, 28 percent of English speakers are uninsured, compared with 40 percent of those who speak only Spanish. “Enrolling in publicly funded health programs and other programs is already a challenge, due to the complications of the application process,” said Mara Youdelman, the managing attorney at the National Health Law Program. “You add language issues on top of that, and it just becomes really difficult for families to enroll in these programs.”
That’s because—let’s be honest—insurance application forms aren’t exactly user-friendly, even in English. Applying for coverage in the new regime will require reporting your “gross adjusted income,” for example. Youdelman said one of her projects is to encourage the creation and circulation of a standardized Spanish glossary for such key policy terms. The Health and Human Services Department has clearly been giving these matters some thought. A few weeks ago, it decided to jettison the name “exchange” for the new state health insurance marketplaces created by the Affordable Care Act; one of the considerations was that the word doesn’t translate well into Spanish.
Experts also see the mixed immigration status of many families as a key deterrent to enrollment. In families with, say, undocumented parents and children who are citizens, the parents are often reluctant to sign up for any public program, even though their immigration status is not relevant to the application process under the act. In some cases, immigration lawyers discourage their clients from applying for health benefits, even when immigrants would be eligible, for fear that government assistance could stymie their prospects of earning a green card.
Enroll America is researching ways around these problems. One obvious strategy will be advertising in Spanish-language media—radio talk shows, Univision, and the like may soon be flooded with the voices of doctors telling people they should sign up for new benefits. But the organization is also pursuing more-targeted methods, too. In some cases, it has found that reaching out to English-speaking Latino children may be the most effective way to get parents to an enrollment site. Enroll America is considering a text-message campaign to reach those families. For older Spanish-speakers without young children, churches may be the most trusted source of information, so Enroll America and other groups are planning to train clergy on the details of health reform.
“We have to talk to them, 1) in the way they want to receive it, but 2) being mindful that there are huge differences between different demographics just within the Latino population,” said Martine Apodaca, the group’s public-education director.
While the strategies are still being developed, the stakes are high. The president won reelection because of a wave of Latino voters. To make his signature health care initiative work as planned, he needs them again.
This article appears in the February 9, 2013 edition of National Journal Magazine as Clarion Call.