Much media attention has been given to the potentially shifting voting patterns of the U.S. Hispanic population in the 2020 election. However, far less attention has been given to the implications for this population of newly-enacted or proposed policies that have resulted from that election. With the 2022 midterm elections looming, we believe that these implications, especially those directly related to the health of this population, merit attention for two key reasons. First, the Hispanic population suffers from significant health and healthcare disparities and these new policy initiatives years should be assessed in light of potential for remedying large-scale inequities. Second, evaluating the effects of policies on the health of the Hispanic population will provide a strong indicator regarding how future-oriented these policies are. The Hispanic population is significantly younger than the overall population and includes more than 25% of the nation’s children. So, to positively impact the health and well-being of the Hispanic population is to invest in the nation’s future.
We provide a usable summary, i.e., a kind of report card on the key elements of the Biden agenda and their implications for the Hispanic population. We explicitly consider four of the five major categories of the social determinants of health. Our main focus is three policy areas that are of particular relevance to the health of the Hispanic community: health care, education, and immigration (a key social context factor in the Hispanic community). We also include a brief mention of the impact of the Biden administration’s environmental initiatives. We do not consider the fifth domain, economic stability, per se but include important workplace safety and income stability initiatives related to COVID-19 in the health policy category. Unfortunately, it would be too subjective a task at this juncture to assess the administration’s performance regarding the overall economic impact of their policies. Assessing the role of their policies in contributing to inflation and balancing that against the robust employment landscape is probably better tabled until a longer-term view is possible.
Our analysis proceeds by judging the accomplishments of the administration against its articulated agenda and the relevance of those accomplishments to the needs of the Hispanic community. We conclude that in the arena of health care and environmental justice, the administration’s achievements have been formidable and of great benefit to the U.S. Hispanic population. While the Biden administration has had great ambitions in regard to education and immigration, political realities have meant settling for a couple of worthwhile achievements.
Health Policy in the Biden Administration (Grade A-)
The Biden administration has focused its health policy initiatives on two main goals: (1) ameliorating the ongoing COVID-19 pandemic and (2) increasing access to affordable health care. The pandemic required immediate attention. Shortly after taking office, President Biden signed an executive order to protect worker health and safety from COVID-19. This order included mandatory mask-wearing, partnering with state and local agencies to protect workers, enforcing safety requirements in the workplace, and making additional healthcare resources available. Because Hispanics often work in low-wage, essential jobs that have few protections, they have been disproportionately harmed by unsafe work conditions during the pandemic and benefited by this policy.
Hispanics have not only been disproportionately affected by COVID-19 in terms of infection and death but are also highly impacted by its economic consequences. The impact of the pandemic has been compounded by low wages, fewer job-related benefits, and lack of employment-based health insurance. President Biden’s American Rescue Plan Act of 2021 (ARP) took aim at these economic effects. Key elements of the legislation related to health included extending unemployment benefits, issuing a $1,400 direct payment to individuals, increased food stamp benefits, funding for housing, COVID-19 response funding, and temporary changes to the ACA that enhanced purchasing subsidies.
The American Rescue Plan included $47.8 billion for COVID-19 testing and administering COVID-19 vaccines to low-income individuals and people of color. This is especially relevant because COVID-19 has disproportionally affected the Hispanic community. Furthermore, the ARP included $7.6 billion for community health centers and Federally Qualified Health Centers (FQHC) to address disparities in the distribution of COVID-19 testing. FHQCs provide health care to anyone regardless of ability to pay, and are open to undocumented immigrants, who otherwise have few options yet have been employed in essential jobs during the pandemic. As a result of this funding, the share of Hispanic people vaccinated against COVID19 exceeds their share of the total population. In other words, this disparity has been eliminated at this time. However, it is feared that unless additional funds are appropriated for the new round of variant-specific vaccine boosters, this disparity may recur.
The cornerstone of President Biden’s healthcare agenda is expanding access to quality and affordable healthcare by strengthening and expanding the Affordable Care Act (ACA). Since its inception, the ACA decreased the percentage of uninsured by one-third among Hispanics, arguably the largest increase in coverage for any ethnic group. To reverse the erosion of coverage during the Trump years, President Biden signed an executive order to strengthen Medicaid and the ACA including a special enrollment.
The American Rescue Plan Act also included additional important temporary changes to the ACA that increased the affordability of health insurance. Purchasers are eligible for premium subsidies if a premium exceeds 8.5% of their income thereby eliminating the “subsidy cliff,” expanding low-income subsidies to a larger income pool, and extending automatic eligibility for maximum subsidies to the unemployed. These enhanced subsidies were recently extended for three years in the Inflation Reduction Act. In addition, the American Rescue Plan Act also introduced Medicaid benefits, including coverage of COVID-19 vaccines, options for COVID-19 testing, and incentives to expand Medicaid coverage.
The list of health policy accomplishments of the new administration is impressive when judged by the needs of the Hispanic community. Making access to health insurance more broadly available and strengthening key access institutions such as FQHCs undoubtedly hold promise for the Hispanic community.
Education (Grade: B-)
Education is a key social determinant of health. The Biden educational agenda was articulated during the presidential campaign and came to be included in a series of legislative items known as the “Build Back Better” agenda. It is well-known that it stalled in the Senate and none of the education agenda was included in the truncated version known as the Inflation Reduction Act of 2022.
Of recent note is student loan relief that President Biden has taken by executive action. Borrowers with incomes less than $125,000 qualify for cancellation of up to $10,000 of federal student debt and those who received Pell grants may cancel up to $20,000. It is estimated that forgiving $10,000 cancels more than half of all student loan debt held by Hispanics. This may free many borrowers who wish to pursue additional education but were concerned about the burden of debt already incurred. In addition, this executive action will adjust the income-driven repayment (IDR) plan to five percent of a borrower’s discretionary income. While the loan forgiveness aspect of the action provides a significant one-time boost to the net wealth of the Hispanic community, the IDR aspect will be an important structural corrective to inequities.
It is worth considering the potential impact on the Hispanic community of the now-abandoned educational proposals on which President Biden campaigned and that were included in the House of Representatives’ Build Back Better bill. The central theme of Biden’s educational agenda had been to add two years of free education at each end of the spectrum to the current K-12 educational structure. This would take the form of free universal pre-K and free community college. Both proposals would address key needs of the Hispanic population. Hispanic students typically start Kindergarten behind other students by several months of learning in regard to mathematical skills. A recent study indicated that prior experience in center-based care including pre-schools is associated with higher math achievement among Hispanic children. Furthermore, the percentage of Hispanic and Black children enrolled in high quality pre-school programs is abysmally low.
The Biden proposal for two years (6 semesters) of free community college was an early casualty in the negotiations with the Senate. This provision could have had a highly salutary effect on the educational prospects of Hispanic population. Hispanic youth enroll in college at a lower rate than their white peers and disproportionately utilize public two-year institutions as their point of entry to higher education
However, the Biden administration successfully acted to address the capacity issue at the community college level. Community college capacity has generally been decreasing rather than keeping pace with growing demand from this growing population. Three billion dollars were included in the American Rescue Plan Act of 2021 for Hispanic-serving institutions, historically Black colleges, and tribal colleges to strengthen their academic and administrative capabilities.
In sum, the Biden administration has enacted extremely important initiatives such as student loan forgiveness, reform of the IDR plan, and increased support for community colleges. However, candidate Biden ran on an agenda that likely would have been transformative of the educational prospects of the Hispanic community, adding two years of free schooling at each end of the educational spectrum. Abandoning this agenda so early in this presidency is nothing short of tragic.
Immigration (Grade: D+)
The Biden campaign agenda regarding immigration was ambitious and included delivering legislative reform that would gain a pathway to citizenship for long-time undocumented members of our communities. However, it has become perhaps the most stalled aspect of his legislative agenda with little hope of moving forward. While immigration policy covers many things from practices related to refugees and asylum seekers to the visa system, the policies that have the greatest impact on the health and well-being of Hispanic Americans concern the treatment of undocumented immigrants who are well-integrated into U.S. society. It is estimated that there are approximately 10 million persons without a lawful immigration status residing in the United States. Most have resided in the U.S. for more than 10 years these persons have generally integrated into the fabric of their communities. Approximately 13% of Hispanics in the United States are undocumented and this status negatively impacts key social determinants of health such as poverty and access to health care. The closely-divided Senate has meant that this agenda would have to be included in the budget reconciliation process in order to avoid being filibustered.
In order to be included in the budget reconciliation bill, provisions must be measures that mainly implement spending or tax policy. The measures should not be primarily policy initiatives whose budgetary impact is incidental to the policy change. Immigration reform seemed to be a strong candidate to fit this model because it is long-established that the economy would reap a significant benefit from providing these millions of workers with the ability to work lawfully. Unfortunately, the Senate Parliamentarian ruled that three different proposals by Senate Democrats did not qualify for budget reconciliation. These proposals ranged from granting a pathway to citizenship to millions of million undocumented workers to legislating a deferred action status that includes eligibility for work permits. However, the parliamentarian ruled against these proposals and the Democrats did not have the votes to take actions such as override these rulings. This has set immigration reform back to the proverbial “square one” in the Senate.
The main accomplishment regarding immigration in the Biden administration is its efforts to strengthen DACA through taking appropriate administrative procedural steps. These procedural steps will help DACA to survive future court challenges by its opponents. DACA affects almost 700,000 young people, most of whom are Hispanic. Supporting this program is clearly important even if it is a limited achievement.
In sum, the failure to move forward any significant immigration reform measures pertaining to undocumented immigrants leaves millions of long-time Hispanic Americans in a kind of limbo that limits their ability to care for themselves and their families and to achieve a modicum of security and stability that is foundational to a healthy life.
Environmental Initiatives (Grade: A)
Climate change affects the well-being of the entire planet. As a result, it can seem strange to consider environmental initiatives from the perspective of one population. However, as the Biden campaign articulated, communities of color and low income communities are often the sites for disproportionate pollution, e.g., sites of industrial production may be located there and Hispanics bear a correlative higher illness burden despite contributing less to the production of pollution than their white counterparts. Similarly, communities of color suffer disproportionately from hazards in the infrastructure such as lead in their drinking water. The administration’s bipartisan infrastructure package contains a number of provisions to promote environmental justice including 15 billion dollars to replace lead piping. While this may not be as large an investment as is ultimately needed, it is an important step forward.
Of course, the signature accomplishment are the incentives in the Inflation Reduction Act to dramatically decrease greenhouse gas emissions by 2030. This puts the administration on track to achieve their ambitious goal of reducing greenhouse gas emissions by 50% below their 2007 levels by 2050. This will be an enormous achievement.
While this environmental justice record is impressive, these accomplishments are probably the least likely to make an impression on Hispanic voters in the near term.
Conclusion (Overall Grade: B)
The Biden agendas on health care, education, immigration, and the environment promised to greatly benefit the Hispanic community in the U.S. and play a pivotal role in the future of the United States. However, the record of achievement to this point has been mixed. The emergency bills and executive actions that were enacted soon after the inauguration as well as the infrastructure and environmental legislation have provided for important investments and reforms. The political realities of narrow legislative majorities may necessarily mean that two years of free pre-school and community college, and immigration reform would not be able to be enacted. However, these proposals would be transformative of the health and well-being of sizable portions of the Hispanic community. They cannot be allowed to be forgone forever. What happens next to them will be a test of the future political will of the Hispanic voter.
Cesar Montelongo Hernandez, PhD, is a graduate student in the MD-PhD program at Loyola University Chicago. He is the first DACA recipient in the U.S. to complete such a program.
Sullibet Ramirez is a third-year medical student and the founder of the DACA Wellness Committee at the Loyola University Chicago Stritch School of Medicine.
Joanne Suarez, MBe is the founder of Latinx Bioethics.
Mark Kuczewski, PhD is Professor of medical ethics and director of the Neiswanger Institute for Bioethics and Health Policy at the Loyola University Chicago Stritch School of Medicine.