Congress must pass a bill this week to keep most of the government running beyond Friday, when a government spending bill runs out. It won’t be easy.
The debate over a new spending bill focuses on an esoteric issue affecting the Affordable Care Act.
The question is whether Congress will pass — and President Donald Trump will sign — a bill that also funds subsidies for lower-income people who purchase health insurance under the law. These “cost-sharing reductions” (CSR) have become a major bargaining point in the negotiations between Republicans and Democrats, because the spending bill will require at least some Democratic votes to pass.
Here are five things to know about these cost-sharing subsidies:Use Our ContentThis KHN story can be republished for free (details).
How are these subsidies different from the help people get to purchase insurance?
There are two types of financial aid for people who buy insurance from an ACA exchange. People with incomes up to four times the poverty line, or $81,680 for a family of three, are eligible for tax credits to help pay their premiums.
In addition to that help, people with incomes up to two-and-a-half times the poverty line, or $51,050 for a family of three, get additional subsidies to help pay their out-of-pocket costs, including deductibles and copayments for care, as long as they purchase a silver-level plan. Insurance companies are required in their contracts with the government to provide these cost-sharing reductions to eligible people, then get reimbursed by the government.
Why are cost-sharing reductions suddenly front and center?
The fight dates to 2014, when Republicans in the House of Representatives filed suit against the Obama administration, charging that Congress had not specifically appropriated money for the cost-sharing subsidies and therefore the administration was providing the funding illegally.
A year ago, a federal district court judge ruled that the House was correct and ordered the payments stopped. However, she put that ruling on hold while the Obama administration appealed. That’s where things stood when Trump was inaugurated.
If the Trump administration drops the appeal, the funding would cease. However, Congress could also opt to approve funding the payments, which is what Democrats are pushing in the spending bill.
What would happen if these subsidies are stopped?
At the very least, ending the cost-sharing reductions in the middle of the year would cause a serious disruption in the insurance market. The payments are estimated at $7 billion this year, and $10 billion in 2018. They cover about 7 million people, about 58 percent of those purchasing coverage on the exchanges.
Many experts have predicted that if the subsidies end, some or all insurers might leave their markets entirely, leaving consumers with fewer, or possibly no, choices.
But even if they stay, the Kaiser Family Foundation estimates that insurers would have to raise premiums on the marketplace silver plans by an average of 19 percent in order to offset that loss of government reimbursement. (Kaiser Health News is an editorially independent program of the foundation.)
Ironically, ending the subsidies would actually cost the federal government more money. Premium increases to make up for the lost payments would in turn trigger bigger tax credits for the broader population eligible for help paying their premiums. Those larger tax credits would cost the federal government an estimated $2.3 billion above what it would save on the cost reduction subsidies next year, KFF projected.
Who is pushing Congress to fund the subsidies?
In addition to Democrats in Congress who support the ACA, influential health-related groups are urging lawmakers to fund the cost-sharing reductions.
The coalition, which includes America’s Health Insurance Plans, the American Medical Association, the American Hospital Association and the U.S. Chamber of Commerce, points out that the uncertainty surrounding the future of the promised payments could not only disrupt this year’s insurance market, but next year’s as well.
“The window is quickly closing to properly price individual insurance products for 2018,” the groups wrote to Congress on April 12. Most insurers must decide whether they will participate in the health law’s market in 2018 by late June.
Most Americans don’t support cutting the subsidies as part of a GOP strategy to force Democrats in Congress to help pass a new health law. A recent poll reported 60 percent of those surveyed said the president “should not use negotiating tactics that could disrupt insurance markets and cause people to lose health coverage.” On the other hand, two-thirds of Republicans surveyed said Trump “should use whatever negotiating tactics necessary to win support for a replacement plan.”
What does the Trump administration think about this?
Good question. Trump and senior health officials have offered conflicting positions.
On April 10, unnamed officials told the New York Times and other outlets that the administration “is willing to continue paying subsidies” while the lawsuit remains pending, just as the Obama administration did. The next day, however, a spokeswoman for the Department of Health and Human Services disavowed that statement, saying that “the administration is currently deciding its position on this matter.”
The day after that, Trump himself said in an interview with the Wall Street Journal that he was holding back a decision on the payments as leverage. “I don’t want people to get hurt,” he said. “What I think should happen — and will happen — is the Democrats will start calling me and negotiating.”
By the following week, administration officials were dangling the funding for the cost-sharing reductions in the spending bill as a trade for Trump’s request for funding for a border wall. “We don’t like those [subsidies] very much, but we have offered to open the discussions to give the Democrats something they want in order to get something we want,” budget director Mick Mulvaney said on Fox News Sunday. “We’d offer them $1 of CSR payments for $1 of wall payments.”
Democrats, however, are not buying what the administration is selling. “The White House gambit to hold hostage health care for millions of Americans, in order to force American taxpayers to foot the bill for a wall that the president said would be paid for by Mexico is a complete non-starter,” Senate Minority Leader Chuck Schumer (D-N.Y.) said in a written statement.
Complicating matters further, it is far from clear that Republicans in Congress want to end the cost-sharing payments.
The subsidies are “a commitment made by the government to the insurers and the people,” House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) said at a town hall meeting in his district, according to The Washington Post. “That needs to happen.”
For most of his life, Carl Goulden had near-perfect health. He and his wife, Wanda, say that changed 10 years ago. Carl remembered feeling “a lot of pain in the back, tired, fatigue, yellow eyes — a lot of jaundice.”
“Gray-like skin,” Wanda added. His liver wasn’t working, she explained. “It wasn’t filtering.”
Carl was diagnosed with hepatitis B. He is now 65 and on Medicare, but back then he had a flower shop in Littlestown, Pa., so he had been buying health insurance for his family on the market for small businesses and the self-employed.
The medications to manage Carl’s hepatitis cost more than $10,000 a year — and if he ever needed a liver transplant, as some people with hepatitis eventually do, the costs could be formidable. Thank goodness they had health insurance, the couple thought.This story is part of a partnership that includes WHYY, NPR and Kaiser Health News. It can be republished for free. (details)
But then, Carl said, “the insurance renewals went way up.”
After a few years, he could no longer afford to buy the coverage — more than $1,000 a month — and maintain his business. So he dropped the insurance.
“I was devastated,” he said, “because I didn’t know when my liver might fail.”
Teresa Miller, Pennsylvania’s insurance commissioner, said that steep increase in insurance rates was legal. And before the Affordable Care Act became law, a patient like Goulden might have had a hard time buying another policy. He likely would have been turned down by private insurers because he had a “preexisting” medical condition.
A family like the Gouldens would “just have been out of luck,” Miller said.
Pennsylvania: The Wild, Wild West
Before the ACA, states had differing approaches to handling preexisting conditions.
Pennsylvania was typical. Until the ACA mandated that insurers treat sick and healthy people equally, buying insurance seemed as lawless as the Wild West.
Insurers couldn’t overtly kick people off a plan if they got sick, but they could find ways to charge them much more, even those whose chronic condition wasn’t that serious — such as acne. For individuals looking to sign up in the first place, “an insurance company could simply decline to offer you insurance at all because of your preexisting condition,” Miller said.
Insurers who did offer a policy to someone with a preexisting condition might have done so with a catch — the plan could require a waiting period or might exclude treatment for that condition.
“So, let’s say you had diabetes, for example,” Miller said. “You might have been able to get coverage for an unexpected health care need that arose, but you’d still be on your own for any treatment and management of your diabetes.”
From the perspective of an insurance company, these practices were intended to prevent the sick from signing up for a health plan only when they needed costly care.
Pennsylvania tried to partially solve this problem by creating a scaled-back health plan, called adultBasic, for those with incomes too high to qualify for Medicaid who didn’t have any coverage. Household incomes had to be less than 200 percent of the federal poverty level, which at that time would have been $21,660 for an individual. More than 40,000 people were signed up in 2011, and nearly half a million were on the waiting list, but the plans didn’t include coverage for mental health care, prescription drugs or more than two nights in a hospital. Even so, Miller said, the strategy proved too expensive for the state.
“That program was spending $13 million to $14 million a month when it was shut down,” she said.
More than 30 other states dealt with preexisting conditions by setting up what are called high-risk pools, a separate insurance plan for individuals who couldn’t get health coverage in the private market.
These plans could be lifesavers for some people with conditions like cancer — which can cost tens if not hundreds of thousands of dollars to treat.
The experiences with high-risk pools varied, but states faced challenges, said John Bertko, an insurance actuary with the state of California. And the main problem was the high cost.
“The one in California, which I was associated with, limited annual services to no more than $75,000, and they had a waiting list. There was not enough money,” Bertko said. “The 20,000 people who got into it were the lucky ones. At one point in time, there were another 10,000 people on a waiting list.”
The pools also had catches: Premiums were expensive, as were out-of-pocket costs. And plans often excluded the coverage of preexisting conditions for six months to a year after the patient bought the policy.
New Jersey: Preexisting Conditions Covered, With A Catch
Around that same time, across the Delaware River, the state of New Jersey was trying something different.
“Insurers could not take health status into account,” said Joel Cantor, director of Rutgers’ Center for State Health Policy who has been analyzing the New Jersey experience.
Before the ACA, New Jersey was one of just a handful of states that prohibited insurers from denying coverage to people with preexisting conditions. Insurers also weren’t allowed to charge people significantly more for having a health issue, and the plans had to offer robust coverage of services.
There was a one-year waiting period for coverage of a preexisting condition, but a larger issue became cost. The entire individual market in New Jersey became expensive for everyone, regardless of their health status, Cantor said. Because there was no mandate to have health insurance coverage, those who signed up tended to need it, and healthy people did not enroll.
And so, “the prices went up and up,” he said. And the premiums and enrollment “went down and down.”
The state tried to address this in the early 2000s by introducing a “skinny” health plan, Cantor said.
“By that I mean very few benefits,” he explains. “It covered very, very limited services.”
The plan was affordable and really popular, especially among the young and healthy people, and about 100,000 people signed up. But if a person had a health need, many costs shifted to the individual.
“It left people with huge financial exposure,” he said.
That’s, in part, why the ACA included a rule that insurance plans now must offer good benefits and be available to everybody. In exchange, insurers have the mandate and subsidies — so that everybody will buy in.
Cantor said these experiences point to an ongoing quandary: A small portion of people consume a big chunk of health care costs. It’s hard to predict who will cost a lot — or when.
Acute shortages of home health aides and nursing assistants are cropping up across the country, threatening care for people with serious disabilities and vulnerable older adults.
In Minnesota and Wisconsin, nursing homes have denied admission to thousands of patients over the past year because they lack essential staff, according to local long-term care associations.
In New York, patients living in rural areas have been injured, soiled themselves and gone without meals because paid caregivers aren’t available, according to testimony provided to the state Assembly’s health committee in February.
In Illinois, the independence of people with severe developmental disabilities is being compromised, as agencies experience staff shortages of up to 30 percent, according to a court monitor overseeing a federal consent decree.
The emerging crisis is driven by low wages — around $10 an hour, mostly funded by state Medicaid programs — and a shrinking pool of workers willing to perform this physically and emotionally demanding work: helping people get in and out of bed, go to the bathroom, shower, eat, participate in activities, and often dealing with challenging behaviors.
It portends even worse difficulties to come, as America’s senior citizen population swells to 88 million people in 2050, up from 48 million currently, and requires more assistance with chronic health conditions and disabilities, experts warn.
“If we don’t turn this around, things are only going to get worse” said Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association, which represents nursing homes across the U.S.
“For me, as a parent, the instability of this system is terrifying,” said Cheryl Dougan of Bethlehem, Pa., whose profoundly disabled son, Renzo, suffered cardiac arrest nearly 19 years ago at age 14 and receives round-the-clock care from paid caregivers.
Rising Demand, Stagnant Wages
For years, experts have predicted that demand for services from a rapidly aging population would outstrip the capacity of the “direct care” workforce: personal care aides, home health aides and nursing assistants.This KHN story also ran in The Washington Post. It can be republished for free (details).
The U.S. Bureau of Labor Statistics estimates an additional 1.1 million workers of this kind will be needed by 2024 — a 26 percent increase over 2014. Yet, the population of potential workers who tend to fill these jobs, overwhelmingly women ages 25 to 64, will increase at a much slower rate.
After the recession of 2008-09, positions in Medicaid-funded home health agencies, nursing homes and community service agencies were relatively easy to fill for several years. But the improving economy has led workers to pursue other higher-paying alternatives, in retail services for example, and turnover rates have soared.
At the same time, wages for nursing assistants, home health aides and personal care aides have stagnated, making recruitment difficult. The average hourly rate nationally is $10.11 — a few cents lower than a decade ago, according to PHI, an organization that studies the direct-care workforce. There is a push on now in a handful of states to raise the minimum to $15 an hour.
Even for-profit franchises that offer services such as light housekeeping and companionship to seniors who pay out-of-pocket are having problems with staffing.
“All the experienced workers are already placed with families. They’re off the market,” said Carrie Bianco, owner of Always Best Care Senior Services, which is based in Torrance, Calif., with franchises in 30 states.
Finding new employees was so difficult that Bianco started her own 14-week training program for caregivers nine months ago. To attract recruits, she ran ads targeting women who had left the workforce or been close to their grandparents. In exchange for free tuition, graduates must agree to start working for her agency.
“There’s much more competition now — a lot of franchises have opened and people will approach our workers outside our building or in the lobby and ask if they want to come work for them,” said Karen Kulp, president of Home Care Associates of Philadelphia.
Hardest to cover in Kulp’s area are people with disabilities or older adults who live at some distance from the city center and need only one to two hours of help a day. Workers prefer longer shifts and less time traveling between clients, so they gravitate to other opportunities and “these people are not necessarily getting service,” she said.
It isn’t possible to document exactly how common these problems are nationally. Neither states nor the federal government routinely collect information about staff vacancy rates in home care agencies or nursing homes, turnover rates or people going without services.
“If we really want to understand what’s needed to address workforce shortages, we need better data,” said Robert Espinoza, vice president of policy at PHI.
Hard Times In Wisconsin
Some of the best data available come from Wisconsin, where long-term care facilities and agencies serving seniors and people with disabilities have surveyed their members over the past year.
The findings are startling. One of seven caregiving positions in Wisconsin nursing homes and group homes remained unfilled, one survey discovered; 70 percent of administrators reported a lack of qualified job applicants. As a result, 18 percent of long-term facilities in Wisconsin have had to limit resident admissions, declining care for more than 5,300 vulnerable residents.
“The words ‘unprecedented’ and ‘desperate’ come to mind,” said John Sauer, president and chief executive of LeadingAge Wisconsin, which represents not-for-profit long-term care institutions. “In my 28 years in the business, this is the most challenging workforce situation I’ve seen.”
Sauer and others blame inadequate payments from Medicaid — which funds about two-thirds of nursing homes’ business — for the bind. In rural areas, especially, operators are at the breaking point.
“We are very seriously considering closing our nursing facility so it doesn’t drive the whole corporation out of business,” said Greg Loeser, chief executive of Iola Living Assistance, which offers skilled nursing, assisted living and independent living services in a rural area about 70 miles west of Green Bay.
Like other short-staffed operators, he’s had to ask employees to work overtime and use agency staff, increasing labor costs substantially. A nearby state veterans home, the largest in Wisconsin, pays higher wages, making it hard for him to find employees. Last year, Iola’s losses on Medicaid-funded residents skyrocketed to $631,000 — an “unsustainable amount,” Loeser said.
Wisconsin Gov. Scott Walker has proposed a 2 percent Medicaid increase for long-term care facilities and personal care agencies for each of the next two years, but that won’t be enough to make a substantial difference, Loeser and other experts say.
The situation is equally grim for Wisconsin agencies that send personal care workers into people’s homes. According to a separate survey in 2016, 85 percent of agencies said they didn’t have enough staff to cover all shifts, and 43 percent reported not filling shifts at least seven times a month.
Barbara Vedder, 67, of Madison, paralyzed from her chest down since a spinal cord injury in 1981, has witnessed the impact firsthand. Currently, she qualifies for 8.75 hours of help a day, while her husband tends to her in the evening.
“It’s getting much, much, much more difficult to find willing, capable people to help me,” she said. “It’s a revolving door: People come for a couple of months, maybe, then they find a better job or they get pregnant or they move out of state. It’s an endless state of not knowing what’s going to happen next — will somebody be around to help me tomorrow? Next month?”
When caregivers don’t show up or shifts are cut back or canceled, “I don’t get proper cleaning around my catheter or in my groin area,” Vedder continued. “I’ll skip a meal or wait later several hours to take a pill. I won’t get my range-of-motion exercises, or my wheelchair cushion might slip out of place and I’ll start getting sore. Basically, I start losing my health.”
Debra Ramacher and her husband have been unable to find paid caregivers since June 2015 for daughter Maya, 20, and son Michael, 19, both of whom have cerebral palsy, epilepsy and other significant disabilities. The family lives in New Richmond in western Wisconsin, about 45 minutes from the Minneapolis-St. Paul metropolitan area.
“At least three agencies told me they’ve stopped trying to hire personal care aides. They can’t find anybody and it costs them money to advertise,” said Ramacher, executive director of Wisconsin Family Ties, an organization for families with children with emotional, behavioral and mental disorders.
“It’s incredibly stressful on all of us, living with this kind of uncertainty,” she said.
Every few months, Ramacher tries to find caregivers on her own by putting ads up on Craigslist, in local newspapers and on job boards.
“We get a few bites,” she said. “Most recently, two people came and interviewed. One never got back to us; the other got a better job that paid more.”
In the meantime, she and her husband are being paid by Medicaid to look after Maya and Michael.
“We don’t want to be the caregivers; we want to have our own life,” Ramacher said. “But we don’t have any option.”
KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.
LIMA, Ohio — Speaking over constituents’ often-hostile shouts and angry murmurs, one of Congress’ most conservative Republicans told a tense town hall meeting here Monday that less government regulation — not more — is the solution to their rising health care premiums.
“What we want to do is make sure we have the best health care system in the world and bring back affordable insurance plain and simple. That’s what I’m trying to do. That’s what we continue to focus on,” said Rep. Jim Jordan, the co-founder of the House’s conservative Freedom Caucus. Its firm opposition to the GOP’s plan to replace the Affordable Care Act forced party leaders last month to yank their bill from a vote on the House floor.
But on the eve of Congress’ return to Washington after a two-week Easter recess, Jordan offered no clues to his party’s next move on a health care bill or the prospects for a government shutdown if Congress fails to agree before the Friday deadline on a bill to provide short-term funding to keep it operating.Use Our ContentThis KHN story can be republished for free (details).
More than 200 people attended the Ohio congressman’s 2 1/2-hour meeting, mostly pummeling him with questions and personal stories about their health care. Jordan heard from constituents with sick children, veterans who couldn’t access Veterans Affairs’ care and nervous families who feared what could happen to them if federal Medicaid funding is cut, among others.
Seated on black folding chairs in a windowless hall of the Lima Veterans Civic Center, many in the audience followed a practice that’s been common this year at congressional members’ town hall meetings — holding up red signs when they disagreed with Jordan and, less frequently, green signs when they agreed. Jordan, unruffled by opposition, drew laughs once when he referred to a woman in the crowd as “gentlelady,” in the formal way that male members of Congress sometimes address female members when the House is in session.
Tobias Buckell told the congressman the ACA’s mandate that insurers cover preexisting conditions had made it possible for both his wife, Emily, and him to have careers as freelancers — he as a science fiction writer and Emily as an e-book designer. Buckell, the father of twin 8-year-old daughters, told Jordan the only way he could risk that career choice was because he was able to buy insurance through the law’s exchanges. He has a genetic heart condition that he said had made him virtually uninsurable before.
“We’re going to be moved to a high risk pool, we’ll pay three times as much our current rate … how will that help me?” asked Buckell, 38.
Though the most vocal members of the crowd were largely in disagreement with Jordan’s views, a quiet minority in the front of the room shook their heads and waved green signs in agreement when the congressman responded to a question by saying he did not believe health care is a universal right.
“I do not believe health care is a right. Rights are not given to us by the government, rights come from God, although Jim acknowledged that the American people have come to accept it as a right,” said Linda Gentry, a 66-year old constituent who works for an insurance company.
Of the 17 questions Jordan was asked, 13 related to health care. Lisa Robeson, the event’s moderator, estimated that around half of the 45 questions submitted in advance focused on the topic.
Jordan’s comments on the federal government’s role in solving the opioid crisis brought what might have been his audience’s most negative reaction of the night.
Ohio has been especially hard hit in recent years. It led the nation in opioid overdose deaths in 2015, according to the Kaiser Family Foundation, while Dayton, just an hour and a half south of Lima, topped a criminal justice group’s national ranking of America’s most drugged-out cities last year.
“I’m not convinced the federal government giving more money will solve the problem,” Jordan said. Instead of a “grand scheme” handed down from Washington, he suggested churches, schools and families are best equipped to handle the opioid epidemic – a remark that raised a sea of red signs across the room.
Jordan’s 4th District touches the northern part of the state near Lake Erie, and includes rural areas and suburbs of Columbus, the state capitol. He has been the district’s congressman since 2007 and he has little reason to be alarmed by contentious town halls. Jordan was reelected last November with more than 68 percent of the vote.
By the end of Monday’s town hall, some of Jordan’s constituents were divided on whether they’d heard what they came to find out.
“It’s clear to me that there is sort of a vague idea what the Republican replacement would be, and I don’t think we got a statement about that,” said Robert Kemp, 62, a health care economist that also rose to speak in favor of universal health care.
Barbara Mayer, 81, a retired teacher, didn’t mind the lack of specificity. She said it was unfair for people to demand comment on a measure that hasn’t been finalized yet.
“They’re quoting things about what Trump’s bringing out and it isn’t even public yet,” Mayer said. “People aren’t giving the new Congress a fair trial.”
BALTIMORE – Peter Uribe dejó Chile a los 21 años con su esposa y su hija de 2, aterrizando en Baltimore y encontrando un trabajo estable en la construcción. Su vida social giraba alrededor del fútbol, deporte que practicaba ”seis o siete noches a la semana en distintos torneos”, contó.
Un par de años después de su llegada, se rompió el pie durante un partido y, temeroso de lo que le podía costar un tratamiento, no buscó atención médica.
“Algunos en mi familia me advirtieron que, si iba al hospital y no podía pagar la factura, tendría un historial de crédito malo”, dijo Uribe, de 41 años, que ganaba cerca de $300 por semana y no tenía seguro de salud. “Algún día quería comprar un auto o una casa”. En vez de eso, cojeó durante las horas de trabajo y permaneció fuera del campo de juego por tres años. Dos décadas después, el dolor que siente todavía lo paraliza.
Por razones económicas y culturales, los hispanos no quieren interactuar con el sistema de salud. Las mujeres de todas las razas tienen más probabilidades de buscar atención que los hombres. Pero la brecha de género en la comunidad hispana es especialmente preocupante para los proveedores de atención médica. Estudios muestran que los hombres latinos son mucho menos propensos que las latinas a recibir tratamiento.
Y esto es una verdad, aun cuando los hispanos son más propensos que los blancos no hispanos a ser obesos, tener diabetes o hipertensión. Aquellos que toman tienden a beber mucho, contribuyendo a mayores tasas de cirrosis alcohólica y muertes por enfermedad hepática crónica. Muchos toman trabajos de riesgo, como los obreros de la construcción y los jornaleros, y tienden a morir más a causa de lesiones en el trabajo que otros trabajadores, muestran datos del gobierno.Use Nuestro ContenidoEste contenido puede usarse de manera gratuita (detalles).
Los hispanos pasarán a ser un cuarto del total de la población para 2045. A medida que este número crece, los investigadores temen que el país podría enfrentar consecuencias costosas ya que las condiciones médicas que son ignoradas llevan a enfermedades más graves y a discapacidad.
“Podría literalmente quebrar el sistema de atención de salud”, dijo José Arévalo, presidente de la Junta de Médicos Latinos de California, que representa a médicos hispanos y a otros que atienden a latinos.
Y ahora, algunos médicos también temen los efectos de la represión del presidente Donald Trump contra los inmigrantes ilegales.
“Cuando la comunidad se enfrenta a este tipo de estrés, me preocupa que la gente haga cosas poco saludables, como abusar del alcohol, para enfrentar el problema”, dijo Kathleen Page, co-directora del Centro SOL, un centro de salud en el Johns Hopkins Bayview Medical Center, y fundadora del Latino HIV Outreach Program de la ciudad. “Eso significa que pueden no trabajar tanto”, agregó. Por lo que “tendrán menos dinero, lo que significa que es menos probable que busquen atención”.
Bienvenidos por funcionarios de Baltimore, los inmigrantes han impulsado la población hispana de la ciudad, triplicándola a 30.000 desde el año 2000.
Aquí, como en otros lugares, la evidencia sugiere que, para muchos hispanos, buscar atención médica es un evento extraordinario. Los datos de los hospitales muestran que son más propensos que las mujeres hispanas, y los hombres y mujeres blancos no hispanos a usar las salas de emergencia como su principal fuente de tratamiento, una señal de que esperan hasta no tener otra opción más que buscar ayuda.
Algunos proveedores de atención dicen que las instituciones médicas no han hecho lo suficiente para mantener a los hombres hispanos sanos, o para persuadirlos de hacerse exámenes regulares.
“Hay una necesidad continua de que las instituciones se adapten más culturalmente y sean más conscientes de los prejuicios”, dijo Elena Ríos, presidenta de la National Hispanic Medical Association, que representa a los 50,000 médicos latinos de la nación.
Hay algunas diferencias significativas en el riesgo de salud y las tasas de enfermedad entre los subgrupos hispanos, por ejemplo, los puertorriqueños son más propensos a ser fumadores. En comparación con los hispanos nacidos en los Estados Unidos, los nacidos en otros lugares tienen tasas mucho más bajas de cáncer, enfermedades del corazón y presión arterial alta. En general, los hispanos viven más que los blancos no hispanos.
“Le digo a la gente que vivimos más tiempo y sufrimos más”, dijo Jane Delgado, psicóloga clínica cubanoamericana, quien es presidenta de la National Alliance for Hispanic Health.
Los expertos que investigan brechas en las pruebas de cáncer han descubierto que todos los grupos étnicos y géneros han visto una disminución en los diagnósticos de cáncer de colon en etapa terminal y las muertes en los últimos años, excepto en los hombres hispanos, que se hacen la colonoscopía en tasas más bajas que cualquier raza o grupo étnico.
A menudo, los problemas de salud surgen después de que los inmigrantes se enfrentan a una barrera con el seguro médico. Años después de que José Cedillo viniera a Baltimore desde Honduras, el cocinero de 41 años notó que sus piernas se entumecían y le dolían con frecuencia. Preocupado por el dinero, evitó el tratamiento y siguió trabajando, hasta que finalmente fue a una clínica, en donde le diagnosticaron diabetes.
En los siete años que han pasado desde entonces, su salud se ha deteriorado tanto que no puede trabajar, con frecuencia no tiene un techo en donde dormir y pasa largos períodos en el hospital. Como inmigrante que llegó a los Estados Unidos sin papeles, no es elegible para cobertura pagada por el gobierno o para recibir dinero por discapacidad. Y no puede pagar los medicamentos. En cambio, dijo: “Bebo para adormecer el dolor”.
Otra parte del problema es que los hispanohablantes están subrepresentados entre los profesionales médicos. Después de llegar aquí, a los miembros de la familia de Uribe los acompañaba un sobrino o sobrina que hablaba inglés cuando podían permitirse el acceso a médicos. De lo contrario, “íbamos lejos para encontrar un médico que hablaba español”, dijo.
Con frecuencia, los hospitales carecen de servicios multiculturales y de personal bilingüe, admiten los administradores. Aunque los latinos representan casi el 20% de la población, sólo el 7% de las enfermeras registradas y el 5% de los médicos son hispanos. La brecha se ha ampliado a medida que más hispanos han llegado a este país durante las últimas tres décadas, según un estudio de la Universidad de California en Los Ángeles publicado en 2015.
“Demasiado seguido, la gente no entiende lo que usted está diciendo, no sabe lo que usted va a cobrar, qué restricciones dietéticas les estamos aconsejando”, explicó James Page, vice presidente para diversidad en Johns Hopkins Medicine. “Esto crea un problema de confianza para los hispanos. Tenemos que mejorar la forma de atenderlos”.
Esto es particularmente cierto en la salud mental. Sólo el 1% de los psicólogos en los Estados Unidos son hispanos, lo que significa que los hombres de habla hispana que buscan terapia probablemente tendrán que esforzarse para encontrarla en su lengua materna.
En Baltimore, sólo hay un grupo de apoyo en español para hombres que sufren de ansiedad y depresión, dicen psicólogos locales y defensores de los latinos. La ciudad emplea a un consejero para abuso de sustancias que habla español. Un puñado de trabajadores sociales bilingües de la ciudad ofrecen sesiones de asesoramiento a tarifas reducidas y sólo tres psiquiatras ofrecen sesiones de terapia en español.
Para Peter Uribe, la clave para mantener la salud de su familia es conseguir ayuda para pagar la atención. Su esposa y su hermano sufren de ataques epilépticos, y Uribe contó que el desánimo de su hermano hizo que él mismo se deprimiera. En 2015, obtuvo seguro para su familia a través de un programa de caridad. Con la ayuda de medicamentos ahora asequibles, las convulsiones de su esposa disminuyeron, y él buscó ayuda para su depresión crónica. Como ahora habla inglés, encontrar consejería es más fácil.
En enero, después de la intervención de un grupo de defensa de los latinos, la caridad renovó la póliza de salud de los Uribe por dos años. Pedro Uribe lo llama una bendición:
“Sinceramente no tengo ni idea de lo que haríamos sin este seguro”.
Michael Anft es periodista y escritor, y vive en Baltimore. Su trabajo aparece regularmente en AARP: The Magazine, The Chronicle of Higher Education y otras publicaciones. Daniel Trielli, periodista especializado en datos en Capital News Service, en el Philip Merrill College of Journalism, contribuyó para este informe.
La cobertura de Kaiser Health News sobre disparidades de salud en el este de Baltimore es apoyada por The Annie E. Casey Foundation.