Written Statement of UnidosUS

Submitted to

U.S. Senate Committee on Finance

Hearing to Consider Graham-Cassidy-Heller-Johnson Proposal

Submitted by

Janet Murgua
President & CEO
UnidosUS
Raul Yzaguirre Building
1126 16th Street, NW, Suite 600
Washington, DC 20036-4845

September 25, 2017

Introduction
UnidosUS, formerly the National Council of La Raza, is the largest national Hispanic* civil rights
and advocacy organization in the United States. For nearly 50 years, we have worked to
advance opportunities for middle- and working-class Latino children and families, including
immigrant and mixed-status households, to achieve the highest level of health possible. In this
capacity, UnidosUS and its Affiliate Network of nearly 300 Affiliates have worked to ensure that
all peopleregardless of who they are or where they are fromhave access to affordable,
quality health care.

Advancing health equity is crucial for all Americans, including Latinos who are still more
likely to be uninsured than other Americans. The Affordable Care Act (ACA) has helped
drive us closer to health equity. Since the implementation of this law, more than four
million Latinos gained coverage and the rate of uninsured Latinos plummeted to a record
lowfrom 43.2% in 2010 to 24.8% in 2016.1 Still, this progress is fragile. While the number
of uninsured Latinos has fallen dramatically because of the ACA, in 2016, 40% of uninsured
adults were Latino.2 Proposals that we have seen to repeal and replace the ACA would
reverse course on these historic gains and put millions of people one medical emergency
away from financial devastation.

As evidence of our commitment to improving access to health care, UnidosUS has

published several reports on coverage gains and what the ACA means to the Latino
community:
Latino Childrens Coverage Reaches Historic High, But Too Many Remain Uninsured,
published by UnidosUS and the Georgetown Center for Children and Families
(December 2016)
Historic Gains in Health Coverage for Hispanic Children in the Affordable Care Acts
First Year, published by UnidosUS and the Georgetown Center for Children and
Families (January 2016)
Latino Health at Risk: What the American Health Care Act Means for Latinos
separate publications for Arizona, Colorado, Florida, and Nevada, published by
UnidosUS and FamilesUSA (June 2017).

UnidosUS strongly opposes the Graham-Cassidy-Heller-Johnson bill (Graham-Cassidy), the

latest in a long string of attempts to repeal and replace the ACA. By some estimates, this
bill would lead to at least 30 million people losing coverage, deep cuts and restructuring of
the Medicaid program, weakening or eliminating protections for people with preexisting
conditions, and skyrocket out-of-pocket costs for consumers. It is not surprising that so
many stakeholders have publicly expressed their opposition to the bill, including a
bipartisan group of governors, all 50 state Medicaid directors, the American Academy of

*
The terms Hispanic and Latino are used interchangeably by the U.S. Census Bureau and throughout this document to refer
to persons of Mexican, Puerto Rican, Cuban, Central American, Dominican, Spanish, and other Hispanic descent; they may be of
any race.

2
Pediatrics, and Americas Health Insurance Plans (AHIP). Hardworking Americans, including
Latinos, cannot afford the implications of this bill.

This written statement will focus on the importance of the ACA program to the Latino
community, concerns with the Graham-Cassidy proposal, and recommendations for
strengthening the ACA by stabilizing the marketplace.

The ACA Has Led to Historic Gains for Latino Coverage

Overall, the ACA has made health coverage a reality for 20 million Americans, including
four million nonelderly Latino adults.3 Since the provisions went into effect in 2013, the positive
effects have been clear.

Over four million Latinos, including children and young adults, have benefitted from
the ACAs provisions. The ACA has provided coverage to mostly nonelderly adults4.2
million. It is important to note that figure includes over 900,000 Latino young adults
between the ages of 19 and 26. These young Latinos would otherwise be uninsured, but
have coverage under their parents plan because of the ACA.4 Additionally, over 600,000
Latino children have gained coverage since 2013 because of health coverage
expansions, including the ACA.5

The ACA has brought the Latino uninsured rate down to historic lows. Between 2013
and 2015, the overall Latino uninsured rate declined to 16.2%, the lowest rate ever
recorded.6 This dramatic reduction is due, in large part, to the ACA. This law is also
thought to have influenced a similar decline in the Latino child uninsured ratewith the
largest two-year decline on record between 2013 and 2015 (11.5%7.5%).7 This decline
also brought the uninsurance rate for Latino children to a record low.

States that expanded Medicaid under the ACA have experienced the largest decline in
the uninsured rate for nonelderly Latino adults. In these states, the average uninsured
rate for nonelderly Latino adults was 22%, compared to 36% in states that elected not to
expand.8 California, which expanded its Medicaid program, experienced the largest
percentage point decline in the nonelderly Latino adult uninsured rate of any state
(38%20%).9

Most Latinos know that the ACA is working. Nationwide, nearly three out of four Latino
voters (71%) believe that the ACA is working well or mostly working well, and should
remain in place.10 Moreover, the August 2017 Kaiser Health Tracking Poll found that
overall, most adults (60%) thought it was a good thing that Republicans did not repeal
the ACA.

Concerns with Graham-Cassidy Bill

The Graham-Cassidy bill, the latest effort from Senate Republicans to repeal and replace the
ACA, makes one thing clear: the health and well-being of the American people is not a priority.
Instead, this bill makes harsh cuts to fundamental health care programs like Medicaid, while
3
making it more difficult for working- and middle-class Americans to access health insurance. In
this spirit, Graham-Cassidy includes the most injurious parts of previous repeal-and-replace bills
and adds other provisions that will do even more harm. While a full score from the
Congressional Budget Office (CBO) does not exist, the CBO score of previous repeal attempts
can serve as a useful proxy of the effect this bill would have on health coverage in 2027 when
all block grant funding to the states is cut off.11 Specifically, for the Obamacare Repeal
Reconciliation Act, the CBO estimated that 32 million people would lose coverage if funding for
state Medicaid expansion programs and premium subsidies were eliminated by 2027. In fact, it
is likely that coverage loss would be even greater due to the addition of Medicaid per capita
caps this bill imposes on our children, seniors, and the disabled.

The Graham-Cassidy bill threatens the well-being of millions of Americans, but stands to have a
greater negative effect on the Latino community. This bill puts everyone with Medicaid
coverage, or receiving premium subsidies in the ACA marketplace, at risk of losing access to
health coverage, or being forced to pay more for it. However, Latinos will be disproportionately
harmed by this proposal, because they are more likely to count on the federal programs, like
Medicaid and ACA premium subsidies, which are singled out for major cuts. UnidosUS has four
key concerns with this harmful proposal from Senate Republicans.

The Medicaid program as we know it would end. Like other repeal and replace bills,
Graham-Cassidy would restructure and cut funding for the rest of Medicaid, outside of the
ACAs Medicaid expansion. The proposal caps the amount of federal funding available for
traditional Medicaid beneficiaries like children, people with disabilities, and low-income
seniors. Between 2020 and 2026, Medicaid spending for the traditional Medicaid
population will be cut by an estimated $175 billion, including by $39 billion in 2026 alone.12
These cuts will force states to cut benefits, cap the number of enrollees, or both.
o A cap on Medicaid spending would hit Latinos the hardest, as one-third of Latinos,
including over half of all children, count on Medicaid for health coverage.13
o Latino children, who are part of the traditional Medicaid population, account for a
majority of Medicaid/CHIP enrollees. Over half of Latino children count on Medicaid
for coverage and would see their benefits or enrollment affected by drastic cuts.14

The Medicaid expansion provision under the ACA and marketplace subsidies would end.
Graham-Cassidy would eliminate the ACAs Medicaid expansion and marketplace subsidies
starting in 2020. The proposal includes cutting federal funding for state Medicaid expansion
and premium subsidies by $236 billion from 2020 to 2026 and offers smaller and insufficient
block grants. States would not be required to spend block grant funds on lowering health
care costs for low- and moderate-income children and families; they could spend this
money virtually any way they please. Losing both provisions would leave millions of
Americans vulnerable to a coverage loss.
o Eleven million Americans, including three million Latinos, who gained Medicaid
coverage because of state expansions, would be at risk of losing coverage.15
o Nearly 9 million Americans, including most Latinos, who use premium subsidies to
purchase individual marketplace coverage, would be at risk of losing coverage.16
4
 Graham-Cassidy shifts federal funds from Medicaid expansion states to nonexpansion
states. Under the proposed block grant structure, overall funding for Medicaid expansion
and subsidies will be cut, but in 2021, reduced federal funding would be redistributed
across states. The allotment would be based on their share of low-income residents rather
than actual spending. This means that over time, states that expanded Medicaid and
effectively enrolled citizens in the ACAs health insurance marketplace would be punished,
including states with large Latino populations, like California, Florida, and New York.17 While
all states will see reductions over time, at least initially, states that did not expand or work
to enroll low-income people would see less damaging cuts or even increased funding
initially. In all, 36 states, plus DC, would face net federal funding cuts in 2021. In the long
run, every state will face net funding cuts when block grant funding ends after 2026.18

States that lose the most federal funds for Medicaid and premium subsidies include states
with significant Latino populations like Arizona, California, Colorado, Florida, New York, and
Nevada.
o A total of 9.2 million Latinos are enrolled in Medicaid coverage in these states.19
o California stands to lose the most with a $27.8 billion cut in federal funding for
health care costs and covering low- and moderate-income people by 2026. Other
states will face significantly reduced funding as well: New York by $18.9 billion,
Florida by $2.7 billion, Arizona by $1.6 billion, Colorado by $823 million, and Nevada
by $639 million.20

Graham-Cassidy weakens consumer protections under the ACA, including those for people
with preexisting conditions. This bill would allow states to waive the ACAs prohibition
against charging higher premiums based on the existence of health conditions or health
status. The U.S. Department of Health and Human Services estimates that up to 133 million
nonelderly Americans may have a preexisting condition.21 States applying for a waiver
would only be asked to explain how they intend to maintain access for people with pre-
existing conditions; they would not need to submit any proof that their plan would
accomplish that. Furthermore, this bill also ends the requirement that insurers cover
essential health benefits including hospitalization, maternity care, and prescription drugs.

Strengthen Existing Law via Bipartisan Solutions

Congress has the power and responsibility to prioritize the health and economic security of the
American people. I urge you to reject efforts to strip health care away from those who need it
most and instead focus on taking bipartisan legislative action to reduce uncertainty in the
health insurance marketplace, hold down premiums, and bolster access to health coverage for
more Americans. While the opportunity to improve the law for the coming year may slip past
amid efforts to repeal, work must be done to strengthen the law in the future. An important
starting point would be to continue work on bipartisan legislation to stabilize the marketplace
that prioritizes the following:

5
 Make the cost-sharing reduction (CSR) payments permanent. Congress should create a
permanent funding stream for CSR payments. Sixty percent of people with marketplace
coverage use CSR payments to significantly reduce their out-of-pocket health care costs. The
Congressional Budget Office estimates that terminating these payments would cause
benchmark silver plan premiums to increase by an average of 20% and cause one million
people to lose coverage.

Reinstate and fund the ACAs reinsurance program. Congress should reinstate and make
permanent the reinsurance program to facilitate increased insurer participation in the
marketplace and lower costs. When it was funded, the ACAs reinsurance program resulted in
lower premiums for consumers. In 2014, the reinsurance program reduced premiums by 10
14%. Similar savings would help more Americans attain coverage this open enrollment period.

Prioritize 2018 Latino open enrollment outreach and enrollment efforts. Congress should
appropriate funds and instruct the Department of Health and Human Services (HHS) to
provide enrollment resources and assistance for all consumers. Congress should also direct
HHS to prioritize communities of color, those with limited English proficiency (LEP), immigrant
and mixed-status families, as well as the LGBTQ community. These communities historically
have had lower coverage rates and are more likely to be new to our health care system than
other consumers. Our work with Affiliates over four open enrollment periods demonstrates
that in-person, in-language, and culturally competent consumer outreach and assistance is
the most effective way to engage the Latino community, including LEP and immigrant
families. These resources are critical this year, given the compressed open enrollment period
and the uncertainty surrounding the administrations enforcement of the ACA.

Conclusion
While the ACA is not perfect, the historic impact of the law cannot be denied. It has proven to
be successful in expanding coverage, improving health outcomes, and increasing financial
security to 20 million American people. Despite that, this law is under attack again. With each
proposal purporting to strengthen the ACA, the stakes for the American people are raised and it
becomes clearer that positioning people and families for better health and greater economic
security is not a priority for this Congress. We strongly oppose any planincluding the Graham-
Cassidy billthat undermines tens of millions of Americans who have finally been able to
obtain quality, affordable health insurance and that asks the sickest and poorest among us to
bear the brunt of health care costs. These proposals are just cruel. Every senator who is
considering voting for the Graham-Cassidy bill must realize they are voting to jeopardize the
lives and financial stability of working families back home. You can, and must, do better. Any
national health reform proposal should focus on giving more people, not fewer, the
opportunity for quality, affordable, and accessible health care. The health and economic
security of our country demand it and the American people deserve no less.

6
1
The Commonwealth Fund, Millions more Latino Adults are Insured Under the Affordable Care Act. (Washington,
DC, The Commonwealth Fund, 2017), http://www.commonwealthfund.org/publications/blog/2017/jan/more-
latino-adults-insured.
2
Ibid.
3
Assistant Secretary for Planning and Evaluation, Health Insurance Coverage and the Affordable Care Act.
Washington, DC, 2015.
4
Assistant Secretary for Planning and Evaluation, Report Shows Affordable Care Act Has Expanded Insurance
Coverage Among Young Adults of All Races and Ethnicities. Washington, DC, 2012.
5
Ibid.
6
U.S. Census Bureau, Health Insurance Coverage in the United States: 2015, Current Population Reports.
Washington, DC, 2016.
7
Georgetown Center for Children and Families and NCLR, Latino Childrens Coverage Reaches Historic High, But
Too Many Remain Uninsured, (Washington, DC: Georgetown Center for Children and Families and NCLR, 2016),
http://publications.nclr. org/handle/123456789/1672 (accessed January 2017).
8
Ibid.
9
Ibid.
10
National Council of La Raza and Latino Decisions, Health Policy Survey: October 1219, 2016 (Washington, DC:
NCLR and Latino Decisions, 2016).
11
Congressional Budget Office, H.R. 1628 Obamacare Repeal Reconciliation Act of 2017. Washington, DC, 2017,
https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52939-hr1628amendment.pdf
(accessed August 2017).
12
Jacob Leibenluft et al., Like Other ACA Repeal Bills, Cassidy-Graham Plan Would Add Millions to Uninsured,
Destabilize Individual Market (Washington, DC: Center on Budget and Policy Priorities, 2017).
13
Kaiser Family Foundation, Distribution of the Nonelderly with Medicaid by Race/Ethnicity, (Washington, DC:
Kaiser Family Foundation, 2015) http://kff.org/medicaid/state-indicator/distribution-by-raceethnicity-
4/?currentTimeframe=0; (accessed May 2017); and Center for American Progress, Hispanic Children Receiving
Health Insurance Through Medicaid by State, 2015 (data table, Center for American Progress, 2017).
14
Annie E. Casey Foundation, Children who have health insurance by health insurance type and by race and
ethnicity (Baltimore, MD: Annie E. Casey, 2016) and Joan Alker, Tara Mancini, and Martha Heberlein, Snapshot of
Childrens Coverage by Race and Ethnicity (Washington, DC: Georgetown CCF, 2017).
15
National Council of La Raza analysis of U.S. Census Bureau, 2015-2016 Annual Social and Economic
Supplement, Current Population Survey. Washington, DC, 2016, https://www.census.gov/programs-
surveys/cps/data-detail.html with assistance from the Center on Budget and Policy Priorities (CBPP); and Centers
for Medicare and Medicaid Services, Total Medicaid Enrollees VIII Group Break Out Report, (Washington, DC: U.S.
Department of Health and Human Services, 2016) https://www.medicaid.gov/medicaid/program-
information/downloads/cms-64-enrollment-report-jan-mar-2016.pdf.
16
CMS, 2017 Marketplace State-Level Open Enrollment Public Use File, downloaded from
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-
Products/Plan_Selection_ZIP.html (accessed June 2017).
17
Jacob Leibenluft et al., Like Other ACA Repeal Bills, Cassidy-Graham Plan Would Add Millions to Uninsured,
Destabilize Individual Market (Washington, DC: Center on Budget and Policy Priorities, 2017).
18
Ibid.
19
Kaiser Family Foundation, Distribution of the Nonelderly with Medicaid by Race/Ethnicity, (Washington, DC:
Kaiser Family Foundation, 2015) http://kff.org/medicaid/state-indicator/distribution-by-raceethnicity-
4/?currentTimeframe=0; (accessed May 2017).
20
Jacob Leibenluft et al., Like Other ACA Repeal Bills, Cassidy-Graham Plan Would Add Millions to Uninsured,
Destabilize Individual Market (Washington, DC: Center on Budget and Policy Priorities, 2017).
21
Office of the Assistant Secretary for Planning and Evaluation, Health Insurance Coverage for Americans with Pre-
Existing Conditions: The Impact of the Affordable Care Act. U.S. Department of Health and Human Services.
Washington, DC, 2017.