Back in June the Supreme Court narrowly upheld the landmark Affordable Care Act (nicknamed “Obamacare”), which has already helped millions get and keep health insurance. Importantly, the law made it illegal for health insurance companies to deny individuals coverage because of a preexisting condition, including HIV. But there are other changes and considerations that go along with the law, and Daniel Tietz, the executive director of the AIDS Community Research Initiative of America, helps flesh out what benefits (and possible drawbacks), it could bring you.
Click through to find out how the AFA affects Medicaid, the cost of HIV treatment drugs, and potential changes to the law.
Are there immediate changes people need to be aware of with the Affordable Care Act?
The expansion of coverage up to age 26 on your parents’ or family’s health insurance happened last year. It appears to be the only thing to explain the decreased number of young adults without insurance, according to Census data. The end of preexisting condition exclusion has already happened. The end of lifetime caps on coverage already happened. With regard to women and preventative services, there’s now free HIV screening and counseling available, well-women exams, free HIV testing for women age 30 years and older, and other specific services in regard to HIV, HPV, and STI counseling. The next big thing is January 1, 2014; that’s when Medicaid expansion happens in a big way.
Do many receive HIV care through Medicaid, the federal insurance program for low-income people?
Estimates are about half of people with HIV get their care through Medicaid. That number was initially expected to jump with the ACA—70% of those people who weren’t already getting their care through Medicaid would be eligible to do so. That number’s been lowered a bit. The Supreme Court in the end of June said the Medicaid expansion could not be “coerced” by the Department of Health and Human Services. That was the one thing that was removed from [the bill by the Supreme Court]. We’ve heard blather from some governors about whether they’re signing up for Medicaid expansion or not. I think they’re making that noise because it’s an election year. If the president wins reelection, I think they’ll get on board.
The biggest reason is the money. The Medicaid expansion in the first two years—2014 to 2016—will have the federal government picking up 100% of the tab. Then it drops to 90% from 2020 forward. Medicaid is a federal-state split, as opposed to Medicare [which insures seniors and the disabled], which is fully paid by federal taxes. Medicaid was always voluntary. States didn’t have to sign up. When Medicare and Medicaid were created in 1965, only a handful of states were clamoring to get on board. In fairly short order, they all took it. The deal offered then was much worse than the deal offered now. For example, the worst deal you could get from the federal government in regards to splitting the cost of Medicaid is 50/50. Well-off states, as in annual per capita income of its residents, have a 50/50 split. States that have the best deal in terms of how much the federal taxpayer picks up, well, the best in the country right now is Mississippi. Given that its per capita income is low, it has 73% of its Medicaid costs picked up by federal taxpayers. Before the Affordable Care Act, the best [any state] could ever get was 83%.
So states aren’t spending extra money by expanding Medicaid?
They are and they aren’t. There’s no one answer for that, there are 50 answers for that and the District of Columbia. States that already had a fairly generous Medicaid program, because of the expansion now paying so much of the services, could see their costs go down even as they expand the numbers eligible.
So it may benefit wealthier states that already contribute a lot.
Exactly. Admittedly, for states that had, in relative terms, lousy programs, like Mississippi, their costs are going to go up. Not as much as people think. Now their enrollment is going to go way up, but their costs won’t go up nearly as much. The Kaiser Family Foundation estimates, at the outside, a 4.8% rise in costs in some states, mostly in the South. But in the scheme of things, if you’ve got 40% or 50% increase in enrollment and you only have costs go up 4.5% or 5%, that’s pretty remarkable.
It’s funny the states making the most stink about it, Wisconsin, Texas, and Florida, aren’t very poor.
Texas has the worst numbers in the country in terms as the number of insured. More than a quarter of Texas’s population has no health insurance coverage. Wisconsin has a relatively expansive Medicaid program at present—it’ll see a tiny rise in its costs, according to KFF. Florida isn’t in as bad a shape in the number of uninsured as Texas.
Before the ACA, you wouldn’t qualify for Medicaid just by being low-income, you had to have a preexisting condition.
That’s right. In most states, if you were a childless adult, you had to be disabled to qualify. That will change. Essentially, now it’s just a measure of your income. If you make under $14,000 a year, you’re going to be eligible for Medicaid, no matter who you are. What the Department of Health and Human Services is working on right now are essential health benefits, what the package looks like, and what they’re going to require of states…what Medicaid’s going to deliver, what private insurers are going to deliver in those state-based exchanges [online marketplaces that will be available for people to compare, choose, and buy affordable health insurance] for those who aren’t poor—what they require of that is going to make all the difference in the world. For example, there’s a low bar being set for drug coverage. You know how vital antiretrovirals are for people with HIV. Right now the HHS requires only one drug per drug class or category, but there can be a bunch of drugs in a single class of antiretroviral drugs. If your state only offers up one, as far as HHS is concerned, they’ve met the requirement. We’re urging stronger protections at the federal level. In the course of trying to reduce the criticism over the ACA, HHS has been rather generous in telling the states, “You can set this up the way you want.” For many advocates, particularly on the HIV side, we don’t like that. We were really hoping with the ACA, we would finally get to a consistent place about what kind of coverage folks would have for medications, primary care, and services.
Will the ACA change the cost of meds considerably?
If you’ve got Medicaid, your meds will be paid for. So it becomes literally what drugs that state is willing to pay for—either as part of the Medicaid expansion or part of the state-based exchanges. If you can believe it, those will be different. There’s a package of essential health benefits that come as part of the Medicaid expansion, and there’s a package of what the essential health benefits will be as part of the state-based exchanges. It’s confusing. The ACA is not quite the thing we had hoped for, at least not yet. It’s going to take more advocacy to get there. Activists are arguing that the HHS should make the essential health benefits with the drugs more consistent for Medicaid and the state-based exchanges.
Will there be chances to refine the bill?
All that action is literally happening right now. There were comments due in September, there are decisions that the federal government will make between now and January 1. Everyone thinks those decisions will be made after the election.
For more information on the Affordable Care Act, visit ACRIA.org or HealthCare.gov.