Building on the legacy of the Affordable Care Act

Meet Kealoha Fox

In ʻōlelo Hawaiʻi, or Hawaiian language, the traditional proverb O ke kahua mamua, mahope ke kūkulu means “set a firm foundation first, then build upon the framework and shape its impact.” To Asia-Pacific Leader Kealoha Fox, that’s exactly what the Affordable Care Act (ACA) has done. She considers the landmark legislation’s passage to be a cornerstone of health reform’s foundation.

Eleven years later, as a mom, innovator, and a leader in our Leaders: Asia-Pacific program, Kealoha is building on that foundation by expanding access to health care for Native Hawaiians and Pacific Islanders through her work at AlohaCare.

Kealoha Fox, Asia Pacific Leader

I choose to be part of the solution because we all deserve a better future.”

—Kealoha Fox, Asia Pacific Leader

Check out the conversation we had with Kealoha on how the ACA has impacted her work to get more Hawaiians covered and cared for—and how young people can get involved in taking care of their own communities.

Q: To get started, can you share what inspired you to expand access to health care for those who need it most?

A: I’ll share a recent story of my own, the story of too many of our families. My son is seven-years-old now and was in critical need of glasses. His glasses cost $400 after the insurance deductions. When we went to pick them up, I was reminded with sadness that my grandmother didn’t have the money to pay for my mother to get glasses when she was in elementary school, even though she couldn’t see the chalkboard. My grandma was a single mom then who lived in poverty and struggled for many years to care for her two kids alone in the 1960s.

Kealoha Fox laughs and holds her son.

Kealoha Fox and her son, 2018.

55 years later, single women like my grandma come to AlohaCare everyday with the same needs because the same structures perpetuate disparities. That privilege and responsibility weighs on me daily. I choose to be part of the solution because we all deserve a better future.

Q: And how did you first get started in health reform work?

A: I started my work for health reform while training as a clinician in a federally qualified health center. I served people of color in a rural community—my own people who are Native Hawaiians, those who are experiencing houselessness, and recent immigrants—who had to drive more than an hour to get to the nearest hospital.

At school, I always thought I was going to be treating patients all day, every day. But when you see the unfair and unequal treatment of people living in a medically underserved area, you cannot help but join them in solidarity and in action. After four-and-a-half years there, I was recruited into the government to move from treating individuals toward advancing systemic solutions. I was young and really fired up to take on the barriers that stood against me, my colleagues, and our patients from living our fullest and best health.

Kealoha Fox hugs another leader as she smiles.

Kealoha Fox welcomes leaders at the Hawaiʻi Design Workshop, 2018.

We see culture as a strength to health equity.”

—Kealoha Fox, Asia Pacific Leader

Q: Can tell us about your current work and who you serve?

A: I’m proud to lead Social Health Integration for Medicaid and its Children’s Health Insurance Program (CHIP), as well for Medicare members at AlohaCare, a local non-profit managed care plan founded by the community. Our services provide 100 percent free health care coverage to 75,000 members in Hawai‘i—72 percent of whom are women, infants, and children; 84 percent of whom are Black, Indigenous, people of color (BIPOC); 58 percent of whom speak a language other than English; and many of whom are immigrants from Asia and migrants from the Pacific. The majority of our members live within the federal poverty guidelines, which qualifies them for Medicaid and CHIP.

My programs address the social determinants of health, where social, cultural, and physical services and programs promote good health and improve community well-being in Hawai‘i. We see culture as a strength to health equity, and provide services that aren’t typically prioritized by insurance plans. Our social need focus areas for this year are: 1) accelerating food security and nutrition of members, 2) increasing housing stability for members, and 3) improving pregnancy health among birthing members. Because of COVID-19, I’m always busy and the stakes couldn’t be higher. Part of my daily process means dismantling control of who (or what) gets covered and how we consider health needs beyond medical conditions within a reform framework.

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Q: What do you remember about the passing of the ACA? How did you feel?

A: When the ACA passed, I was working in state government where federal action drives local resourcing for important issues like health care, education, transportation, the environment, and infrastructure. I’m a health policy nerd, so I will never forget when the law passed—it was a historic moment on the tough road of health reform. Now, we know the ACA has generated one of the largest expansions of health coverage in US history!

Without the ACA passing and having time for its provisions to be in place and expanded, I think the health impacts during the COVID-19 pandemic would have been much worse, especially now that we know how dangerous COVID-19 is for people with pre-existing conditions. This means that the ACA has saved lives. We didn’t know that 11 years ago, but we certainly know it now because I see its political, financial, social, and clinical returns daily.

I was 25 when I wrote my first policy plan adopted by government officials and 26 when I successfully passed my first legislative measure. I feel like I came of age with the ACA. That is a beautiful memory to part of and to help celebrate its anniversary. I can say the ACA is part of my own foundation for why I have this passion.

Q: How has the ACA impacted your current work?

A: My programs are specifically designed to ensure health equity for Medicaid members. The ACA created tremendous expansion opportunities that we have finally started to realize the full benefits of 11 years later. For example, health coverage was expanded for millions of Asian Americans, Native Hawaiians, and Pacific Islanders. As of early 2021, 38 states and Washington D.C. have expanded Medicaid under the ACA. That’s an enrollment increase by nearly 42 percent or 15.9 million people, all from the Medicaid expansion made possible by the ACA!

Additionally, children of families facing economic oppression are better covered. For example, the ACA raised standards to ensure that children in low- and middle-income families can access health coverage. It extended the minimum Medicaid eligibility level for children living in poverty.

We also now have guaranteed coverage for services essential to women’s health. The ACA mandated that health plans include maternity coverage and makes key preventive services available. For example, breastfeeding support services and supplies; annual well-woman visits; and screenings for cervical cancer, HIV, and interpersonal and domestic violence.

I was an enrollee of a new ACA benefit when I was pregnant with my son, where I was able to get the breast pump of my choice fully covered and in-hand before I delivered him. Because of this one change, it was easier to breastfeed even though he arrived a couple weeks early. When you are about to give birth to your first baby, you aren’t thinking about those details and how it became possible for your benefit.

A group of people hold hands in a circular formation at dusk.

Leaders and staff gather at the Hawaiʻi Design Workshop, 2018.

Q: To close, what advice do you have for young leaders out there who want to make a difference, but don’t know how to get started?

A: My advice to young people is to be active in local government and to understand the way policy shapes whatever industry or trade you are part of. Your voice and ideas are so powerful – learn to shape them and be mentored to use them to create positive change that benefits your own community.
In ʻōlelo Hawaiʻi (Hawaiian language), this traditional proverb (no‘eau) guides me, and I hope it resonates with you: I alakaʻi no ke alakaʻi i nā kānaka. ʻIke aku, ʻike mai, kōkua aku, kōkua mai; pēlā ihola ka nohona kaiāulu.

In English, it means “A leader is a leader because of the people you serve. Recognize others, be recognized, help others, be helped; such is the life of community.”

Like the work of the Affordable Care Act and those communities who have secured its success, this saying is a cultural reminder that community leadership requires an exchange of mutual help and reciprocity to others for collective health to be achieved. Like President Obama says, we all have a role to play, and we can all make a difference.

You can learn more about the Leaders: Asia-Pacific program here.

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