Health Coverage and Access to Care in the United States-Mexico Border Region: Implications of the Affordable Care Act (ACA)
Introduction: A multifactorial approach is necessary to improve health outcomes and reduce health disparities for populations living in the US-Mexico border region. Key factors include building on health insurance coverage gains, enhancing the rural health workforce and infrastructure, and assuring accessible, cost effective, culturally and linguistically appropriate health services for a growing border population.
The US-Mexico border spans almost 2000 miles, is predominately rural, has a majority Latino population, and has health disparities when compared to US urban areas and non-minority populations. Intractable disparities in the region relate to social determinants of health including poverty, unemployment, and educational attainment without the social, environmental, and developed health services and coverage infrastructure to promote prevention and manage acute and chronic diseases. Other barriers include language, transportation, literacy, and lack of healthcare providers and insurance coverage.
Several Affordable Care Act (ACA) provisions address the needs of rural and vulnerable US populations. Addressing the unmet needs of rural, underserved, and culturally diverse border populations could significantly improve access to care and health outcomes.
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Background: The ACA expanded health insurance coverage and reduced the uninsured to an historic low of 8.6%, yet such gains are at risk for 2017 and beyond. The challenge is assuring coverage and access to high quality healthcare in a cost-effective manner. The unpopular ACA provisions at risk of repeal include the individual tax mandate requiring minimum essential health coverage or paying a penalty, and the volatile state and federally facilitated ACA Marketplaces offering health insurance plans that have seen dramatic increases in premiums from year to year, and exits by some of the larger insurers. Popular ACA provisions include being able to cover children up to age 26 on their parents’ plan, prohibiting insurers from denying coverage or charging more for pre-existing medical conditions, and expanding Medicaid in 31 states and DC.
The ACA effects on rural, border, and medically underserved areas: increased funding to rural and critical access hospitals, community health centers, and providers and reduced uncompensated care as more were insured. This nurtured infrastructure development to enhance the continuum of coordinated care in rural and urban underserved locations, with the goal of reducing costs through primary and preventive health services, and improving health outcomes. Funding increased to Federally Qualified Health Centers, to the National Health Service Corps (e.g., loan repayment for health professionals working in shortage areas), and to Teaching Health Centers to assure that the training, distribution, recruitment, and retention of health professionals met the needs of those gaining ACA Marketplaces and Medicaid expansion coverage in rural areas.
Healthcare in the US Border Region: Sixty-three percent of the US-Mexico border counties are federally designated as Health Professional Shortage Areas (HPSA’s), and 73% are classified as Medically Underserved Areas (MUA’s). Most of the border population is rural, numbers 13 million currently, and will double by the year 2025.
The largest minority group in the US is the Latino population, and it is one of the fastest growing. Providing culturally and linguistically appropriate health services (CLAS) is essential in addressing health disparities and barriers to care in border populations. Strategies for health providers include addressing the Latino healthcare workforce shortage, organizational training on CLAS Standards, language assistance, and education materials.
Community health centers (CHC’s) can serve as catalysts for improving health outcomes by providing comprehensive, high quality primary and preventive care in rural and border areas, while coordinating appropriate health services with other providers and entities. In rural areas with limited resources, the array of services locally available can be enhanced through mobile clinics, telemedicine, and community health workers. In the four US-Mexico border states of Arizona, California, New Mexico, and Texas over six million people gained coverage through ACA provisions from 2010-15 (TABLE 1).
The ACA provides individuals in underserved rural areas with insurance options based on price, benefits, and quality. Required essential health benefits include outpatient and inpatient hospital care, prescription drug coverage, mental health services, maternity and pediatric care, laboratory and rehabilitative services, preventive and wellness services. The ACA and the Office of Minority Health provide eligibility and enrollment education and assistance on health insurance options. Outcomes data is used to inform and improve evidence-based models of care tailored to address regional health disparities and improve health outcomes in terms of quality, coverage, access, and cost-effectiveness.
Summary: Considerable progress has been made in terms of increasing the number and percentage of the insured and expanding access to health services in the US-Mexico border region. Defending gains, while expanding regional collaboration for health policy and research, health insurance coverage, and culturally and linguistically appropriate services are crucial for 2017 and beyond. Collective planning can overcome formidable challenges and present new opportunities to improve the health and well-being for those living in the US-Mexico border region.
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Ryan P. Casey, MD, Resident Physician, Family & Community Medicine Residency Program, Yuma Regional Medical Center.
Hugo Vilchis, MD, MPH, Professor and Associate Dean for Population Health and Research, Burrell College of Osteopathic Medicine; Executive Director, Burrell Institute for Health Policy and Research.
Daniel Derksen, MD, Professor and Chair of the Community, Environment & Policy Department at the University of Arizona Health Sciences Mel and Enid Zuckerman College of Public Health; Director, Arizona Center for Rural Health.