Obamacare a Major Gain for HIV Patients

A rocky start: Obamacare.
National Journal
Sophie Novack
Nov. 4, 2013, 7:45 p.m.

HIV pa­tients are among those with the most to gain from the Af­ford­able Care Act, as long as new cov­er­age of­fer­ings don’t come at the ex­pense of ex­ist­ing pro­grams.

There are cur­rently more than 1.1 mil­lion people liv­ing with HIV in the United States, with only 37 per­cent re­ceiv­ing reg­u­lar HIV care. This means al­most two-thirds are not, in part as a res­ult of lim­it­a­tions to ac­cess and cov­er­age.

The ACA is about to change that by greatly ex­pand­ing health in­sur­ance op­tions for HIV pa­tients.

First, the law pro­hib­its dis­crim­in­a­tion on the basis of a preex­ist­ing con­di­tion. “Cur­rently, if you have a preex­ist­ing con­di­tion like HIV, you’re un­in­sur­able,” said Jen­nifer Kates, vice pres­id­ent and dir­ect­or of Glob­al Health and HIV Policy at Kais­er Fam­ily Found­a­tion. Un­der the ACA, in­surers can­not deny cov­er­age and can­not charge more for care.

In­surers are also pre­ven­ted from put­ting caps on care. This means they can­not lim­it the amount paid on be­half of the pa­tient an­nu­ally or over a life­time — a huge gain, par­tic­u­larly for a con­di­tion as ex­pens­ive to treat as HIV.

Third, Medi­caid ex­pan­sion un­der the ACA elim­in­ates eli­gib­il­ity re­quire­ments out­side of in­come level. Pre­vi­ously, even very poor HIV pa­tients would not be eli­gible un­less their dis­ease pro­gressed to AIDS, at which point they would be con­sidered dis­abled. Kates calls the pre-ACA Medi­caid re­quire­ments a catch-22. HIV pa­tients “can’t really get on Medi­caid to get cov­er­age for their meds un­til they get really sick be­cause they can’t get meds,” she said.

Un­for­tu­nately, Kais­er es­tim­ates that 43 per­cent of people with HIV live in states that are not cur­rently ex­pand­ing Medi­caid. Al­though not all would be eli­gible, in­di­vidu­als with HIV are more likely to be low-in­come than the over­all U.S. pop­u­la­tion, ac­cord­ing to Kates.

These in­di­vidu­als — as well as those who are in­sured — will con­tin­ue to rely on HIV/AIDS pro­grams such as the Ry­an White Pro­gram and the AIDS Drug As­sist­ance Pro­gram, which provide ser­vices to HIV pa­tients that are not avail­able or af­ford­able oth­er­wise.

However, there has been some con­cern among ad­vocacy groups that the im­ple­ment­a­tion of the ACA may af­fect fund­ing for these pro­grams.

“I ab­so­lutely share that con­cern,” said John Peller, vice pres­id­ent of policy at the AIDS Found­a­tion of Chica­go. “I see the role of HIV pro­grams as work­ing to link people to care and provide sup­port­ive ser­vices that help people stay in med­ic­al care. This also has the be­ne­fit of re­du­cing new HIV cases.”

These ser­vices in­clude things like case man­age­ment and trans­port­a­tion, which help min­im­ize road­b­locks that may be keep­ing pa­tients from stick­ing with treat­ment.

“There is a wide realm of ser­vices that are not part of pub­lic or private in­sur­ance and are not part of the ACA,” said Amy Kil­lelea, as­so­ci­ate dir­ect­or of health care ac­cess at the Na­tion­al Al­li­ance of State and Ter­rit­ori­al AIDS Dir­ect­ors. “In­sur­ance cov­er­age is a game changer for people with HIV. But it doesn’t re­place pub­lic health and the Ry­an White Pro­gram.”

Kil­lelea does not see any­thing hap­pen­ing to destabil­ize the pro­gram in the short term, but thinks the pro­grams will ad­apt as the health care land­scape con­tin­ues to change. “The Ry­an White Pro­gram will and should be im­pacted by the ACA.” she said.

Ac­cord­ing to Health and Hu­man Ser­vices’ Health Re­sources and Ser­vices Ad­min­is­tra­tion, which ad­min­is­ters the pro­gram, Ry­an White isn’t go­ing any­where soon. “Im­ple­ment­a­tion of the Af­ford­able Care Act will help the Ry­an White Pro­gram reach more in­di­vidu­als and ex­tend the pro­gram’s abil­ity to provide com­pre­hens­ive care to in­di­vidu­als liv­ing with HIV/AIDS,” Mar­tin Kramer, dir­ect­or of com­mu­nic­a­tions at HRSA, wrote in an email.

Groups are com­mit­ted to edu­cat­ing HIV pa­tients about the ACA to en­sure they take full ad­vant­age. Kais­er re­leased a new web portal yes­ter­day to help those with HIV nav­ig­ate the health care law. 

“We’re deal­ing with re­stric­ted fund­ing already,” Kil­lelea said. “So there is a tre­mend­ous push in every state to max­im­ize en­roll­ment.”

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