Achieving Cancer Equity by Improving Health Insurance Access for All Latinos

Abstract

Cancer is the top leading cause of death among Latino people. Lack of health insurance is a significant contributor to inadequate cancer detection and treatment. Despite healthcare policy expansions such as the Affordable Care Act, Latino people persistently maintain the highest uninsured rate among any ethnic and racial group in the US, especially among Latino individuals who are immigrants or part of a mixed immigration status household. Recognizing that immigration status is a critical factor in the ability of Latino community members to seek health insurance and access healthcare services, a few US states and the District of Columbia have implemented policies that have expanded coverage to children and adults regardless of immigration status. Expansion of Medicaid eligibility regardless of immigration status may significantly benefit Latino communities, however the facilitators and barriers to enrolling in these programs need to be evaluated to ensure reach and achieve health equity across the cancer control continuum for all Latinos.

Introduction

Cancer, a debilitating condition with an estimated economic cost of over $21 billion nationally in medical spending and lost productivity, ¹ is the first leading cause of death among Latino people aged 45 to 64 and the second leading cause of death among those over 65 years old in the US. ² Although cancer morbidity and mortality can be greatly reduced through preventive care, Latino patients are less likely to be up-to-date with cancer screening and prevention and more likely to be diagnosed with later stage cancers, impacting survival, than non-Latino individuals.^3,4 Latino males, for example, are less likely than their non-Hispanic White peers to be diagnosed at early stage disease due to access barriers for high-quality care.^3,4 Breast cancer, the leading cause of cancer mortality in Latina women, and lung cancer, the leading cause of cancer mortality in Latino men, ³ could be detected and treated early and more effectively through access to screenings (such as mammograms and lung cancer screening) and prevented through access to counseling services (eg, tobacco cessation assistance).^{5 -7} When such access barriers are diminished, Latino individuals show better health outcomes and display health benefits rapidly surpassing the health benefits seen in non-Hispanic White peers.^8,9

Yet, despite well-documented health benefits of having access to health insurance and necessary healthcare services, the Latino community continues to have the largest proportion of uninsured adults (21.2% as of 2022), nearly 4 times higher than Non-Hispanic Whites or Asians and 2 times higher than Non-Hispanic Blacks. ¹⁰ Over the past decade, federal (ie, Affordable Care Act) and state (ie, state Medicaid program expansions) policy initiatives have expanded coverage to low-income disadvantaged populations. The Patient Protection and Affordable Care Act (ACA) substantially increased access to health insurance via state-based Medicaid eligibility expansions and nationwide individual health insurance marketplaces, and mandated that insurances cover preventive services at no out-of-pocket cost for patients. ¹¹ However, despite these healthcare policy expansions, Latino people persistently maintain the highest uninsured rate among any racial or ethnic group in the US, especially among Latino people who are immigrants or part of a mixed immigration status household.^{12 -14}

In 2022, 20 million US residents were Latino immigrants of which 30% are estimated to be undocumented.^15,16 Half of likely undocumented immigrant adults report being uninsured compared to less than 1 in 10 naturalized citizen (6%) and U.S.-born citizen (8%) adults. ¹⁷ Typically, eligibility for health insurance is limited to naturalized immigrants and permanent residents, while other lawfully present immigrants might access coverage through their employers, schools, or international insurance programs. Various federal, state, and local policies (eg, 1996 Illegal Immigration Reform and Immigrant Responsibility Act) have impacted the abilities of legal immigrants to apply for assistance programs such as healthcare programs (ie, Medicaid). ¹⁸ Historically, these policies have undergone multiple changes, sometimes easing or tightening access to these programs. ¹⁹ Consequently, these fluctuations have fostered fear and misunderstanding among both Latino families and healthcare providers, contributing to economic hardships and health issues, and a political climate that promotes fear of discovery and deportation.^{19 -22} These policies also have a negative impact on children.^23,24 Specifically, many children eligible for Medicaid state programs remain uninsured because of the fear of discovery and deportation and misunderstanding among mixed status Latino communities. As a result, 1.6 million Latino children (10% compared to 4% for non-Latino) were uninsured in 2022. ¹⁵ Among undocumented children, as many as 32% are uninsured, compared to only 4% of citizen children with citizen parents. ¹⁷ The wellbeing of children is not only critical to their long-term health but also can impact future generations trajectories.

Recognizing that immigration status is a critical factor in the willingness and ability of Latino community members to seek health insurance and access healthcare services, 12 states and the District of Columbia (as of July 2024) provide coverage for children regardless of immigration status. To date, 6 states (CA, CO, IL, NY, OR, WA) and DC have expanded coverage to adults. CA, OR, and NY expanded Medicaid to all adults. DC expanded coverage via a locally funded program. Illinois expanded their Medicaid program to adults 42 to 64 but imposed a cap, leading to a pause in enrollment. Finally, CO and WA expanded access to marketplace coverage. ²⁵ These eligibility amendments could significantly mitigate care access disparities for many Latino individuals and Latino families, as they are projected to increase access to care to over 1 100 000 ²⁶ Latino adults in these states. Recent data from California ²⁷ report more than 300 000 new enrollments since implementations.

Complex Health Care System

The projected benefit of these eligibility expansions may be subdued by lower than expected enrollment. First, previous evidence shows that compared to non-Latino people, Latino individuals were less likely to be aware of insurance marketplaces, of the Affordable Care Act, and more likely to receive assistance from insurance navigators.^{21,28 -30} The strategies used by these states to communicate about these eligibility expansions are thus important. Second, navigating the healthcare system, insurance eligibility, and comprehensiveness benefits are complex for anyone living the US and can be particularly difficult for those with limited or no English proficiency.^21,31 Language barriers pose significant obstacles to understanding healthcare policies, eligibility, plan comprehensiveness, and enrollment application process. Third, as noted above, immigration-related policies can result in an aversion to enrolling into health insurance, even if eligible. ¹⁸

Uncertain Future

The projected benefit of these eligibility expansions could also be shadowed by increased disenrollment. Between 2020 and April 2023, Medicaid enrollment increased by 32.4%, covering 94.5 million enrollees, reflecting the pandemic-related job loss and amendments and extensions of state Medicaid programs implemented to facilitate continued access to coverage during the pandemic. ³² Those pandemic-era policies ended in May 2023 and have been unwinding, leading to more than 23.8 millions of people losing Medicaid coverage between March 2023 and June 2024. ³³ Immigrants, older adults, children, people who live in rural areas, and people with limited English proficiency are expected to be disproportionately impacted and more likely to lose or experience a gap in insurance coverage.^32,34,35 These changes may have a greater negative impact on the Latino population, especially children in mixed status families. ³⁶

Potential Solutions and Recommendations

Expansion of Medicaid eligibility regardless of immigration status may significantly benefit Latino communities; however, the facilitators and barriers to enrolling in these programs need to be addressed in order to ensure reach and achieve health equity for all Latino people. Research shows that media advertisement, insurance navigators, and community health improvement projects can improve knowledge of health-related information and insurance enrollment.^{37 -40} Studies evaluating dissemination of marketplace insurance information can inform potential options that could aid the Latino community in understanding eligibility to and accessing Medicaid. We recommend that states who are expanding eligibility to health insurance (Medicaid or Marketplace) regardless of immigration status partner with Latino community-based organizations to develop multi-lingual dissemination of eligibility information, utilizing previous strategies (navigation, etc.) shown to be effective. Also, community health centers are perceived as safe places to disclose personal information by the Latino immigrant community.^41,42 In the midst of current expansions, we also recommend the continued partnering of Latino community-based organizations with local community health centers and health insurance navigators to publicize the availability of insurance options and mitigate, to some extent, the “chilling”/fear related to immigration policy.^21,43 These multiprong efforts to engage and support the Latino community in disseminating knowledge of health insurance eligibility and access are needed to effectively promote health equity. Successful efforts will not only boost current enrollment but serve as model for other states planning on expanding insurance eligibility.

In conclusion, access to health insurance is a critical facilitator to receipt of cancer prevention and treatment. Cancer is a leading cause of death among Latino people. These state-based insurance expansions, in combination with successful outreach and partnership with the Latino community could be a significant step forward to reducing health disparities and improving equity across the cancer control continuum in Latino communities.