When future historians write their books on the AIDS crisis in America, this year may need its own chapter to tell how health reform and a national AIDS plan — both new in 2010 — helped to end the epidemic once and for all.
So how does health reform required by the Affordable Care Act — ACA for short — impact people living with HIV/AIDS? Right now, fewer than one in five people living with HIV has private insurance. Nearly one-third do not have any coverage at all. When fully implemented in 2014, ACA will help ensure people living with HIV/AIDS will have secure, stable, affordable health insurance and the relief they need from skyrocketing health-insurance costs.
Medicaid, the federal-state program that provides healthcare benefits to low-income people and people with disabilities, has long been a major source of coverage for people with AIDS, as is Medicare, the federal program for seniors and people with disabilities. The Ryan White Program is another key source of funding for health and social services for people living with HIV/AIDS. Currently, of the nearly 30,000 people living with HIV/AIDS in the Delaware Valley, more than 12,000 of them receive primary care, medical case management and other medical and supportive services through the federally funded Ryan White Program. Yet this funding is not guaranteed from year to year. So advocates must continuously lobby Washington for every dollar, every year.
The ACA will address some, but not all, of these problems. Already, insurers cannot deny coverage to children living with HIV/AIDS. They are also prohibited from canceling coverage for adults or children unless they can show evidence of fraud in an application. And insurers can no longer impose a lifetime cap on benefits. Health insurers offering new plans will have to develop an appeals process to make it easy for enrollees to dispute the denial of a medical claim. ACA brought $160 million federal dollars to Pennsylvania as of July 2010 to provide coverage for uninsured residents with pre-existing medical conditions through a new transitional high-risk pool program, funded entirely by the federal government. It also for the first time gives Pennsylvania, New Jersey and Delaware the option of federal Medicaid funding for coverage for all low-income populations, irrespective of age, disability or family status as soon as the state applies for a special waiver that is available now.
In addition to expanding coverage, the authors of the ACA wisely thought about how the estimated 30 million Americans who will be newly covered by 2019 will get their health care and who will provide the care. So, things like increased federal funding for community health centers and programs to expand the health-care work force will be ramped up.
Access to health care does not guarantee you will have quality coverage or good health outcomes. So ACA requires a comprehensive benefits package that equals that of a typical employer plan and includes prescription drugs, preventive care, chronic-disease management and substance-abuse and mental-health treatment.
These changes, and others that will be available in the months and years ahead, will provide a bridge to 2014, when Americans will have access to affordable coverage options in the new health-insurance exchanges, and insurance companies will be prohibited from denying coverage to Americans with pre-existing conditions. People with low and middle incomes will be eligible for tax subsidies to buy coverage from new health-insurance exchanges that will be operated by states. Your choice of doctors will be protected by allowing plan members in new plans to pick any participating primary-care provider, prohibiting insurers from requiring prior authorization before a woman sees an ob-gyn and ensuring access to emergency care.
ACA was not able to address some major problems that will remain or need some kind of national action, for example drug cost containment and adequate physician reimbursement from the public payment systems. No provision is made in ACA for the tens of millions of people living in the U.S. who are undocumented, a population in great need that will require some sort of safety net for their health care.
NATIONAL HIV/AIDS STRATEGY
Less than three months after ACA was enacted, President Obama released the first-ever National HIV/AIDS Strategy for the United States.
The strategy commits to four major goals over five years:
— Reduce new HIV infections to 42,225 per year (from 56,300 now) — Increase access to care and improve health outcomes for people living with HIV — Reduce HIV-related health disparities — Achieve a more coordinated national response
While the strategy mostly refocuses existing efforts to deliver better results within current funding levels, it also makes the case for new investments. It assumes that while ACA is unfolding, the strategy will make sure that the HIV/AIDS prevention and treatment activities that are implemented respond to both health reforms and the relentlessly uncontrolled HIV epidemic, especially among people of color and those in big cities like ours. The strategy confronts the fact that two-thirds of the people who know their HIV status in America are not in care now — even though in many places including Philadelphia, if you seek HIV care and you have no insurance, you can get it. And that care will be of high quality, too.
The White House took great care to make the national strategy’s goals bold, achievable and fiscally viable. For example, the prevention elements — if implemented — will avert enough new infections to pay for the treatment expansions for people already infected (or soon to be), who must be linked to health care as soon as possible after the moment of infection or diagnosis. The hope is that more people will know and act on their status, few new infections will occur, and the 18,000 HIV-related deaths each year in America will, as the strategy’s vision suggests, be zero. n
Matthew McClain is former chairman of Cities Advocating Emergency AIDS Relief Coalition and founding chairman of HealthHIV.