Clearing New Hurdles: Communities Prepare for Open Enrollment

As fall creeps in and Halloween trick-or-treaters are afoot, it is important to remember that Open Enrollment for the Affordable Care Act begins tomorrow! From November 1st to December 15th, individuals can sign up for coverage on their state’s Health Insurance Marketplace. During the 10-week 2017 Open Enrollment period, 12.2 million Americans got coverage through a marketplace plan and 550,000 of those Americans reside in the South.  Open Enrollment marks a time when individuals not only seek health coverage, but also move forward in their personal and professional pursuits, with protection from the health obstacles that can, too often, turn into health tragedies.

Although millions of Americans will sign up for a health insurance plan during these coming months, approximately 27.3 million Americans still do not have health insurance. A disproportionate share of these individuals resides in the South—a region characterized by its poor health outcomes and long-held resistance to federal expansion of health care benefits. Currently, nine of the 13 Southern states have not expanded Medicaid. This choice explains the large Southern contribution to the uninsured population as well as the coverage gap—individuals who are currently uninsured who would qualify for Medicaid if their state expanded coverage. Arguably, the region could use all the resources available to help tackle the high prevalence of chronic conditions such as obesity, diabetes, and hypertension.

Tomorrow’s launch of the Open Enrollment Period will arrive amid confusion given legislative and administrative threats to the law itself. The White House Administration has shortened the Open Enrollment Period to six weeks, and many of the supporting structures that traditionally encourage and support enrollment have been threatened. These actions have created a great deal of uncertainty. Recently announced changes will have sweeping effects across the nation, and will disproportionately affect the South:

  • Reduced funding for enrollment advertising: The Federal advertising budget has been reduced from 100 million to 10 million.
  • Reduced funding for federal enrollment groups: The Federal navigator budget has been reduced 41 percent with Southern and Midwestern states being hit even harder.
  • Reduced website availability during open enrollment: Every Sunday for a 12-hour period during the open enrollment period, healthcare.gov will be down for maintenance and individuals will be unable to sign up for an insurance plan.
  • Elimination of cost-sharing payments to insurance companies: While consumers who are eligible can still gain access to this additional form of financial help (in the form of lower deductibles, copays, coinsurance, and out-of-pocket maximums), the net result of ending these payments is that insurance companies already priced in the lost revenue into their premiums  – the individuals who are most negatively affected are those who are not eligible for financial assistance.

A recent bipartisan bill presented by U.S. Sens. Lamar Alexander and Patty Murray holds the possibility of addressing some of these changes, but given the backlog in the legislative calendar, and the fact that the Open Enrollment Period is almost underway, the prospects for a deal are not particularly good.

These changes will exacerbate financial constraints and decrease choices for consumers. Fortunately, there are groups across the country that are leading community-driven efforts to improve access to health insurance and affordable health care.

Future public health practitioners host timely dialogue about health policy

Just this past week, public health students at North Carolina Central University organized a panel discussion on the state of health policy in America, with a goal of raising timely questions about current inequities in our system.

Panelists offered expertise and information that covered a range of topics:

  • The basics of the Affordable Care Act, and how to secure in-person assistance
  • Accurate and timely information for consumers who need to make decisions about their individual health care for 2018
  • Healthcare options available through Lincoln Community Health Center and Project Access of Durham County
  • Tools and strategies to mobilize grassroots support and advocacy in support of closing barriers to affordable health care in this country

    Professor Reid and two of her students pose for a photo after the panel.

    Professor Reid and two of her students pose for a photo after the panel.

This event was part of a semester-long engagement to understand the policies and implications of the Affordable Care Act and other health legislation taught by Professor La Verne Reid. These students, our future public health practitioners, are also in the process of translating their dialogue into action by helping community members connect to in-person assistance during the Open Enrollment Period.

Their support, alongside the work of ACA navigators and other grassroots organizers, will be crucial to closing the advertising and in-person capacity gaps resulting from reduced federal grant funding. Students will place more than a thousand calls to consumers over the coming weeks to encourage North Carolina residents to secure in-person appointments with an expert to help them navigate their plan options.

With continued threats to the Affordable Care Act, the future of health policy in America remains uncertain. For those concerned with the health and economic well-being of Southerners, and all Americans, important questions remain about affordability, equity, inclusion, and transparency in our health care system.

For more information about 2018 marketplace plans, visit healthcare.gov. For an application checklist, click here. For NC consumers, please call 855-733-3711 for an in-person appointment, or go online to nchealthconnect.org.

Your Degree, Job, and Chronic Stress: Addressing the Social Determinants of Health

Today is the first post from our 2017-18 Autry Fellow, Rishi Jaswaney. We’re happy to have him at MDC and writing for the State of the South blog!

We’ve all felt it before. That sinking feeling before a big exam, an interview, or when your favorite character on Game of Thrones is “removed from casting” in the throes of battle.

Stress. Side-effects may include: nausea, indigestion, headaches and excessive perspiration.

In limited amounts, stress can motivate us to pursue our personal and professional goals. As stressors pass in and out of our lives, the stress hormone, cortisol, naturally fluctuates, but as challenges persist, cortisol levels remain elevated. When stress is a chronic condition, it can be linked to anxiety, depression, and other developmental and psychological issues. Research documenting income-based patterns in health outcomes—including disparities in who is more likely to experience chronic stress—raises new questions regarding the state of health equity in our nation.

As seen in the Centers for Disease Control and Prevention (CDC) chart below, serious psychological distress is associated with severe health problems, including chronic obstructive pulmonary disease (COPD), heart disease, and diabetes. Even more concerning is the disproportionate clustering of these conditions in high-poverty communities, as reported by the CDC: “A total of 8.7 percent of adults with income below the federal poverty level had serious psychological distress, compared with 1.2 percent of adults with incomes at or above 400 percent of the poverty level.”

The daily economic, educational, and social challenges facing those in poverty can create barriers to health services and lead to poorer health outcomes. This idea is captured in the Social Determinants of Health framework, which The World Health Organization (WHO) has defined as the “the conditions in which people are born, grow, live, work and age.” The general argument is that people in high poverty communities are more susceptible to certain illnesses, have less access to health care providers, and are frequently forced to delay care or medicine for financial reasons. The proximity of clinics, public transportation options, and the quality of food vendors, all affect one’s ability to address health concerns and seek care. As the social determinants of health concept has taken hold, organizations like Kaiser Family Foundation have adopted more nuanced definitions, incorporating more detailed categories, as shown below.

The WHO and others have emphasized how money, power, and the distribution of resources (through institutional decisions and policy implementation) shape community conditions and drive health outcomes. In places where education, employment, and accessibility are falling behind national averages, health outcomes are trailing along with them. For example, in North Carolina, counties with the lowest rates of postsecondary attainment and employment (Robeson and Warren counties) also rank poorly on measures of low birthweight, obesity, and diabetes prevalence. Counties with the highest rates of postsecondary attainment and employment (Wake and Orange counties) have the lowest rates of these indicators.

Source: National County Health Rankings

Source: National County Health Rankings

If education and employment are key drivers of upward economic mobility, then people must be healthy enough to take advantage of these opportunities. There are many narratives about educational attainment as a predictor of health outcomes. Formal education often provides foundational principles of nutrition, healthy behaviors, and general health literacy. Education is also an avenue for insurance benefits through school plans or future employment opportunities.  Lastly, education provides individuals with an intangible set of resources such as social networks, norms, and relationships that can cultivate healthy practices.

It is important to recognize that poorer health outcomes in high poverty areas have been driven by policy that marginalizes low-income communities. The provisions of the Affordable Care Act made strides in addressing issues of healthcare access, but in order to holistically address health equity, we must also consider the underlying environmental, social, and economic factors that enable good health. Improving preventative initiatives, health education, and access to nutritious foods are a few measures that could begin to eliminate these disparities, improve public health, and encourage, rather than hinder, economic mobility. Throughout my Autry year with MDC, I hope to continue shedding light on the social determinants of health that persistently marginalize low-income communities. Stay tuned for more posts on how these issues play out in Southern communities!