That public health issue is just one of the challenges Republicans
face as they attempt to overhaul the Affordable Care Act, a law that
brought health insurance coverage to some 20 million people -
including tens of thousands of Americans living with HIV.
Lawmakers are currently considering repealing the massive 2010 U.S.
health reform law known as Obamacare as soon as this month.
But the roadmap is tentative, and complicated: it would keep the
Medicaid expansion and the new individual insurance plans in place
and delay major changes for up to three years. This would give
Republicans more time to craft a replacement plan, but it is not
clear if individual insurance prices would skyrocket during the
delay or what the new coverage will look like.
HIV experts are among the groups, including insurers and hospitals,
that have started lobbying lawmakers. They want to keep the current
level of insurance coverage in place and say that even "repeal and
delay" would disrupt care, put patients in jeopardy and increase the
risk of transmission of a deadly communicable disease.
Republicans will have the added worry of reducing coverage for an
infectious disease that once represented certain death, but now can
be controlled with daily medications that also keep the disease from
"The evidence is iron-clad that when people with HIV are treated and
their viral load is suppressed, their likelihood of transmitting HIV
goes down to almost zero," said John Peller of the AIDS Foundation
of Chicago. "So, any kind of interruption in care is going to result
in more cases of HIV."
In Illinois, one in three people with HIV gained coverage through
Medicaid expansion or the new individual insurance plans created
under the ACA, according to an analysis compiled for Reuters by the
AIDS Foundation of Chicago.
The number of HIV-positive individuals covered by Medicaid in
Illinois rose by more than 50 percent between 2013 - the year before
the new healthcare coverage went into place - and 2016, when 13,694
people with HIV were enrolled.
HIV experts in Republican states have already been wrestling with
the issue of caring for patients with HIV. Earlier this year, North
Carolina became the 48th U.S. state to permit the use of federal
grant money via the Ryan White HIV/AIDS program to pay insurance
premiums for people with HIV.
"We're late to the party, and now the party may be over," said
Allison Rice, director of the Health Justice Clinic at Duke
University School of Law in Durham.
Insurers, including UnitedHealth Group <UNH.N> and Aetna <AET.N>,
pulled out of Obamacare exchanges for 2017. The plans are offered to
everyone regardless of their health and cover everything from
routine check-ups and emergency room visits to organ failure and
cancer, and insurers said costs of doing that were higher than
Policy experts say the delay to an Obamacare replacement may give
insurance companies little incentive to stick with the Obamacare
individual insurance plans. Insurance companies have asked lawmakers
to keep subsidies in place and make changes they hope will help
stabilize the market, such as delaying deadlines for 2018 plan
"It creates a really difficult environment for insurers to commit to
the market," said Carmel Shachar of the Center for Health Law &
Policy Innovation at Harvard.
Shachar co-wrote a letter signed by 174 national, state and local
HIV organizations urging members of the senate not to repeal or
modify the Affordable Care Act without a clearly defined replacement
That was followed by a letter on Tuesday sent by more than 950 HIV
medical professionals urging Congressional members not to repeal the
Affordable Care Act without a viable replacement plan, and to
sustain the federal commitment to the Medicaid program.
"In most states, prior to the ACA, low-income patients with HIV were
denied Medicaid coverage until they became sick and disabled, and
did not have the resources to participate in health savings
accounts," the group, which included the HIV Medicine Association,
said in a statement.
America’s Health Insurance Plans in December said an immediate
repeal of federal support - particularly federal cost-sharing
programs and Medicaid expansion - would jeopardize care for millions
of Americans and disrupt market stability.
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Vice President-elect Mike Pence told Republican lawmakers on
Wednesday the transition team is "mindful of disrupting the market,"
but signaled that a replacement plan would not be in place at the
time the law is repealed.
"The first order of business" was to "repeal and replace Obamacare,"
Pence told a news briefing, adding that "the architecture of the
replacement" would come together "in the weeks and months ahead."
MEDICAID EXPANSION BOOSTS COVERAGE
Before the ACA was passed, only about 13 percent of people with HIV
had private health insurance and 24 percent had no coverage at all,
according to the Department of Health and Human Services.
Medicaid, which provides insurance for low-income individuals, is
the largest source of insurance coverage for people with HIV,
covering more than 40 percent of HIV-positive individuals, Kaiser
Family Foundation estimates.
In the 31 states plus the District of Columbia that expanded
Medicaid under ACA, the law eliminated rules that prevented all but
pregnant women and the disabled from gaining coverage.
"Obviously, not every state expanded Medicaid, but for the vast
majority that did, this was the single most significant piece of the
Affordable Care Act for people with HIV," said Amy Killelea of the
National Alliance of State & Territorial AIDS Directors (NASTAD).
Another 25 percent of people with HIV are covered by Medicare, the
U.S. insurance program for the elderly and permanently disabled.
Nationwide data on how many of the 1.2 million HIV-positive
individuals in the United States gained coverage through the ACA are
still being tallied, said Kaiser health policy analyst Jennifer
Kates. But policy experts say the impact has been dramatic.
"A lot of what the ACA did that is kind of below the radar is
incredibly important to people living with HIV," said Matthew
Kavanagh, a policy analyst at Health Global Access Project in
Before the Affordable Care Act, he said, people living with HIV "had
huge problems accessing medications and insurance."
In non-expansion states, many people with HIV got their insurance
premiums for Obamacare plans paid through the Ryan White program, a
federal grant program established after the death of the Indiana
teen in 1990 of AIDS. The program funds AIDS Drug Assistance
Programs (ADAP), which pay for AIDS drugs and insurance premiums for
people who are uninsured and underinsured.
"It's the main safety net below Medicaid, below Medicare, below
private insurance," Kates said.
Even if the Affordable Care Act were repealed in full, Ryan White
would be there as a safety net, but the program has a fixed budget
In the past, that has resulted in waiting lists. In September of
2011, nearly 9,300 people were on ADAP waiting lists nationwide,
NASTAD data show.
Killelea said her group intends to work with members of Congress and
the new administration to "underscore the public health and
individual health impact" the ACA has had on people with HIV.
"The ACA opened up new choices for people who were frankly
uninsurable in the United States prior to the ACA."
(Reporting by Julie Steenhuysen; editing by Edward Tobin)
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