By Kristina Robles
No matter what side of the national health care debate that you are on, there is no denying that the Affordable Health Care Act (ACA), or as it is nicknamed Obamacare, made significant changes to the treatment and prevention of HIV/AIDS. Seven years after it was signed into law, the new Trump Administration seeks to repeal and replace ACA, which has many people worried about how this would affect those benefits gained through the act.
On March 23, 2010, the ACA was signed into law, changing how millions of Americans received health care coverage. One significant change, particularly to those living with HIV/AIDS and the people who are at high-risk of contracting the virus, was the expansion of Medicaid. The federally funded health care program provides coverage to low-income or disabled individuals and is the leading payer of HIV care in the country.
The act expanded eligibility to those with incomes at or below 133% of the Federal Poverty Line ($14,400 for an individual and $29,3000 for a family of 4), including single childless adults who were usually denied Medicaid unless they were diagnosed with AIDS. Now single HIV-positive individuals can get the care and treatment they need before the virus progresses to the more serious and life-threatening stage of AIDS. This new expansion is particularly important for many gay, bisexual, and other men who have sex with men (MSM). These populations are the most affected by the HIV epidemic. An epidemic that still has a significant impact on our Long Island community.
There is a false assumption that Long Island, being so close to New York City, is just as affluent as the big city to our West. While the Island is home to some of the countries richest neighborhoods, the reality is that the vast majority of Long Islanders are low to middle class. Unfortunately, due to the high cost of living and limited job opportunities, many Long Islanders live well below the Federal Poverty Line. As stated in a recent Newsday article, the Long Island Association found that just over 185,400 residents fall beneath the threshold, and when adjusted for the region’s high cost of living, they determined that another 56,000 people would be considered impoverished (Newsday, 2017).
More than 300,000 people on Long Island do not know how they will get their next meal (Newsday, 2017). Tragically, many people who are food-insecure[i] and HIV-positive have to decide between food and their life-saving HIV medications. Constant adherence to daily ART (antiretroviral therapy) medications is not only important for the infected person’s health but also to the HIV Epidemic as a whole, as people with undetectable viral loads do not transmit the virus to others. When people have to decide between food and their HIV/AIDS medicines, the fight to end the epidemic becomes more difficult. A very important concern since Long Island is considered to have the highest numbers of HIV cases of any suburban area in the nation. According to the latest New York State HIV/AIDS Annual Surveillance Report (2017), there are 5,685 people living with HIV and AIDS on Long Island, with the white MSM population being the most affected[ii]. These numbers do not include the many more cases that go unreported.
Thanks to the expansions in Medicaid coverage, more people have access to care and prevention services that they would not have been able to afford otherwise. In 2010, the average annual patient cost in the United States was $19,912, with the average person paying $9,360 yearly for ART, the cost of which grows as the infection progresses (Carter, 2010). It is important to note that this estimate does not include any mental health or substance abuse services needed by many HIV-positive patients. The ACA requires Medicaid and other insurers to cover Essential Health Benefits, including mental health and substance use services.
Medicare (a federally funded health coverage for seniors) is another significant payer of HIV care. The ACA is closing the coverage gap, or “donut hole”, during which enrollees of Medicare Part D Prescription Drug Benefit must pay in full for all medical services, drugs, and devices they need. It also makes AIDS Drugs Assistance Programs (ADAP) benefits count toward out of pocket limits, moving people through the gap faster and allowing them to resume coverage. It has been shown that Medicare patients who reach the gap are 57 percent more likely than those with continual coverage to stop taking critical heart medication (Rovner, 2012). It can be easily assumed that important ART and PrEP drugs are also sacrificed.
Beyond the federally funded health care programs, ACA allowed more people to obtain coverage, whether privately or through employers. No longer can an insurer deny coverage to children living with HIV/AIDS or any one with a pre-existing condition, nor can they refuse coverage because of a mistake on an application. Gone are the lifetime caps on insurance benefits that were easily surpassed if one is living with a chronic illness. HIV is a life-long illness, that if acquired at birth or a young age, can easily exceed those lifetime caps, leaving patients with a great financial burden.
For those who are not eligible for Medicaid/Medicare or are not insured under an employer, the act has set up online marketplaces and exchanges where people can shop for the best coverage for them and their families. To help people afford coverage, tax subsidies are available for those with low to middle-class income. The ACA also ensures that people who purchase their own coverage will get similar benefits to a typical employer plan, making sure that not only do they have coverage but access to quality care.
To ensure equal care, the ACA has increased funding for health centers and organizations in underserved areas, with great emphasis on preventative care. Coverage must include HIV screening for people ages 15-65 without additional costs such as co-payments or deductibles.
For all its positive changes for HIV/AIDS care (of which the benefits described above is only a portion), the ACA is not without its problems and criticism. For some, the act was overly regulating, and for others, it was not strict enough. But whether one is conservative, liberal, or somewhere in between there were a few issues that could be agreed on.
The new regulations had caused insurers to react with raising the costs for premiums, deductibles, and copayments. Other insurers have opted to leave the marketplaces and exchanges, which led to higher prices due to the lack of competition. And if an individual is not part of the 80 percent of Americans who are eligible for subsidies, nor does he or she receive insurance through his or her employer, the weight of higher costs could be overwhelming (Abelson & Sanger-Katz, 2016). This could lead to people opting out of coverage altogether or circumvent the open-enrollment rules, making the system less stable (Kodjak, 2016).
Time will tell if President Trump and his team will be able to repeal ACA. What is clear is that whatever the future of health coverage is, those affected by HIV/AIDS cannot be neglected. The HIV/AIDS epidemic has come a long way since its start in the 1980s, but we still have a long way to go before we end it. Equal access to quality health care and prevention services are key to doing so.
Abelson, Reed and Sanger-Katz, Margot (2016 October 25) A Quick guide to Rising obamacare Rates. The New York Times. Retrieved from https://www.nytimes.com/2016/10/26/upshot/rising-obamacare-rates-what-you-need-to-know.html
Carter, Michael (2010 September 27) HIV Treatment Is Costly, Especially For The Sickest Patients. NAMaidsmap. Retrieved from http://www.aidsmap.com/aboutus/Who-we-are/page/1276062/
The Editorial Board (2017 April 2) Push LI Poverty Out Of The Shadows. Newsday. Retrieved from http://www.newsday.com/opinion/editorial/growing-poverty-on-long-island-1.13345480
Kodjak, Alison (2016 November 1) Shopping For Obamacare Opens to Mixed Reviews From Consumers. NPR. Retrieved from http://www.npr.org/sections/health-shots/2016/11/01/500183737/insurance-open-enrollment-opens-to-mixed-reviews-from-consumers
Rovner, Julie (2012 April 17) Seniors In Medicare ‘Doughnut Hole’ More Likely To Stop Heart Drugs. NPR. Retrieved from http://www.npr.org/sections/health-shots/2012/04/17/150823790/seniors-in-medicare-doughnut-hole-more-likely-to-stop-heart-drugs
[i] For Long Islanders that are food-insecure and HIV-positive LIAAC’s Nutrition Health Education program may be able to help provide assistance with obtaining food. Please visit liaac.com or call 1-877-865-4222 for more information.
[ii] While Non-Hispanic whites (1,822 reported cases) are the most affected by HIV/AIDS on Long Island, they are closely followed by Non-Hispanic Blacks (1,683 reported cases), and Hispanics (1,593 reported cases).