Backstretch Health Care & the Affordable Care Act

The recent federal government announcement that employer responsibility for providing health insurance to their employees under the Affordable Care Act (aka “Obamacare”) will be delayed for at least another year is not good news for backstretch workers.

In most of the US, grooms and hotwalkers – the lowest-paid workers on the racetrack – have no health care coverage at all. If they’re injured on the job, they get workers’ compensation payments – and may or may not have a job to come back to when they’ve recovered. And in some states, jockeys and exercise riders who are injured on the track are covered under separate workers comp. pools, like New York’s Jockey Injury Compensation Fund, paid for with a combination of trainer per-stall charges and a percentage of owners’ purse winnings.

But, apart from those job-related injuries, backstretch workers are pretty much on their own when it comes to health care. And, if they have spouses and children, their families are out in the cold as well. With weekly salaries of perhaps $300 to $500, hotwalkers and grooms can’t afford health insurance on their own, and they generally earn just too much to qualify for Medicaid. And few trainers provide health coverage for all their workers.

In at least two states, California and New York, there’s a comprehensive effort to provide at least the basics of a health care system for backstretch workers.

On the West Coast, the California Thoroughbred Horsemen’s Foundation (“CTHF”), founded by trainer Noble Threewitt, operates full-time clinics at Santa Anita and Golden Gate Fields, and also provides once-a week or thereabouts mobile clinics during race meetings at Del Mar, Hollywood, Pleasanton and San Luis Rey Downs. In addition, the CTHF provides assistance with referrals to specialists for injuries or illness that are beyond the scope of the clinics and pays some, though by no means all, of backstretch workers’ hospital costs.

The CTHF is funded by the proceeds of unclaimed pari-mutuel tickets (a declining funding source in the age of internet wagering), and by contributions from the tracks and from the Thoroughbred Owners of California. It recently received a $200,000 anonymous donation, brokered by trainer John Sadler.

Back on the East Coast, the Backstretch Employee Service Team (“BEST”) operates clinics at Belmont and, in-season, at Saratoga. Like CTHF, BEST has a plan for paying backstretch workers’ costs for specialist referrals, medical tests and, within limits, hospital visits. BEST is funded principally by contributions from the New York Racing Association (“NYRA”) and the New York Thoroughbred Horsemen’s Association (“NYTHA”), representing owners and trainers who race at NYRA tracks. BEST also receives significant support from a variety of government grants and from John Hendrickson and Marylou Whitney. You can read more about BEST here, here and here.

Both California and New York also offer at least some dental care to backstretch workers, in California directly through CTHF and at NYRA tracks through NYTHA and the donation-financed dental clinic at Saratoga.

[Disclosure: I’m a member of the Boards of Directors of both NYTHA and BEST and am involved in BEST’s efforts to adjust its programs to the requirements of the Affordable Care Act.]

Because so few racetracks around the country offer any access to health care for backstretch workers, and because working on the track is still something of a gypsy life, with trainers moving their horses from track to track and state to state, workers sometimes save up their medical needs until they’re somewhere that does offer treatment. So, when trainers ship in to Saratoga from, say, Kentucky, or when barns return to Belmont from a winter in Florida, it’s common to see workers lining up at the BEST clinic with a year’s, or a lifetime’s, worth of medical problems. There’s probably less of that in California, just because it’s farther from other major-league racing venues, but in New York it’s a big issue. And it's still unclear how Medicaid or insurance coverage under the Affordable Care Act will work for people who move from state to state.

Under the Affordable Care Act, employers with more than 50 full-time workers will eventually have to offer health insurance. That’s the requirement that was just postponed for a year. But, in any event, there aren’t all that many trainers in the US who have more than 50 employees. Most stables are a lot smaller than that, so their workers wouldn’t have the option of employer-provided health care anyway.

Apart from employer coverage, the Affordable Care Act makes a number of changes that are still scheduled to take effect January 1, 2014, and that will have a big impact on the backstretch.

First, at least in participating states, which include New York and California, there will be a significant expansion of Medicaid, so a number of backstretch workers who now make a little too much to qualify will become eligible for this state-run and federally funded program. Eligibility will now extend to workers making up to 133% of the federal poverty level of income. For 2013, those eligibility limits are $15,282 for a single individual and $31,322 for a family of four.

Second, for those who earn too much to be eligible for Medicaid, the “individual mandate” of the Affordable Care Act will apply, and those folks will be required to obtain health insurance coverage through the “exchanges” that are being set up in participating (read Democratic) states; workers in states where Republicans have blocked implementation of the law will be able to go on a national exchange to find coverage.

The cost of that coverage will be limited to somewhere around 3-4% of gross income for most backstretch workers, depending on their earnings, with tax-credit subsidies available to offset a portion of the premium costs. Even so, it’s safe to predict that many backstretch folks will decide that $60-80 a month (their premium cost after subsidies) is just one expense too many and will decide to forego signing up for coverage and instead take their chances with the imposition of penalties when or if they file their tax returns.

Third, the Affordable Care Act provides no coverage for undocumented non-US citizens or residents and in fact makes it illegal for them to obtain health coverage through the exchanges. That undocumented group makes up a significant share of the backstretch workforce, though no one knows exactly how big a share.

And finally, the Affordable Care Act requires that any health insurance plan, whether offered through the exchanges or by an employer, meet certain minimum standards, including the scope of its coverage and its dollar limits. Unless waivers are granted, that may mean that so-called “mini-med” plans like those now offered by fast-food and retail employers, with low dollar limits and many coverage restrictions, will not be permitted. But, in any event, a “mini-med” plan offered through the CTHF or BEST would not relieve individual backstretch workers of the obligation to sign up for their own health insurance through the exchanges.

So what does all this mean for backstretch workers, and for CTHF and BEST? For certain, the coming into force of the Affordable Care Act won’t eliminate the need for these workers to have some help in getting decent health care. Even for those who qualify for Medicaid or who decide to obtain insurance through the exchanges, there will be co-payments, deductibles and incidental costs that, on the typically low salaries paid at the track, they won’t be able to afford. And for those without a legal immigration status, there won’t be anything at all.

So, at a minimum, backstretch workers will still need access to on-track clinics like those operated by BEST and CTHF, and even, to the extent the clinic sponsors can afford it, to an expanded range of services, including more medical tests and more specialist services.

And backstretch workers will need education to help them take advantage of the expanded care available under the Affordable Care Act, to enroll in Medicaid, for those eligible, and to navigate the online insurance exchanges that are being set up.

Beyond that, there will be economic gaps that need filling in under the Affordable Care Act, to pay premiums, co-payments and deductibles and, especially, to find mechanisms to ensure that undocumented workers, who are ineligible for Medicaid and for exchange-provided insurance, have some kind of safety net that goes beyond showing up at the nearest hospital emergency room.

Because New York and California already have strong organizations -- BEST and CTHF -- providing backstretch health care, there's a good chance that these gaps will indeed be filled in a timely fashion. But things are less sanguine in those states without on-track health programs and where political leaders are actively opposing implementation of the Affordable Care Act. One can only hope that all the stakeholders in the industry will join together to take advantage of the opportunities offered by the Affordable Care Act and to continue to meet the needs of the largely invisible folks who work on the backstretch every day to keep the game going.