By: Eric Brush*—
As this column was being finished, the U.S. Senate was still working on its version of a bill that would replace the Affordable Care Act. Little is known about the bill, which is being drafted by a small group of Republican senators. No public hearings will be held on the bill before the Senate votes on it.
To pass under the budget reconciliation process, the Senate bill will need at least 50 votes, with Vice President Mike Pence as a tie-breaker in the event of a 50-50 tie. Since there are just 52 Republican Senators and no Democratic Senators are expected to vote for AHCA, any bill developed by the Senate can only afford to lose the votes of two Republican Senators. It is not clear when—or whether—the Senate will pass legislation. If they do, then the House and Senate will need to negotiate the differences between the Senate bill and the American Health Care Act, which was passed by the House May 4. That compromise bill will then need to pass both the House and Senate.
The Kaiser Family Foundation (KFF) published a seven-page issue brief, What Is at Stake in ACA Repeal and Replace for People with HIV? , soon after the U.S. House passed the AHCA. The brief examines the potential effects of different Affordable Care Act (ACA or Obamacare) repeal scenarios and related administrative actions on people living with HIV (PLWH). It focuses primarily on three main policy areas of particular importance to PLWH: (1) the future of Obamacare’s Medicaid expansion; (2) changes to the traditional Medicaid program; and (3) the proposed reforms affecting the private health insurance market, including changes to Obamacare’s insurance marketplaces.
Of these policy areas, changes to Medicaid would likely have the greatest impact on people living with HIV, according to KFF. Medicaid is currently the single largest source of health coverage in the U.S. for PLWH, and its role for PLWH has expanded significantly under Obamacare. Before Obamacare took effect, individuals could not qualify for Medicaid based on income alone. Instead, they had to have both a low income and another condition or characteristic—such as disability, pregnancy, or being parents—to be eligible. These eligibility requirements excluded most low-income childless adults from Medicaid coverage, including many low-income PLWH who could not qualify for Medicaid unless they were already sick and disabled, often as a result of developing AIDS. Obamacare changed this by requiring states that expanded their Medicaid programs to cover persons whose incomes were below 138% of the federal poverty level (FPL) based on their income and residency status alone—other conditions or characteristics were no longer required.
By May 2017, 32 states (including the District of Columbia) where an estimated 62% of PLWH live had adopted Medicaid expansion. Under Obamacare, the federal government provided those states with 100% federal funding (often referred to as matching funds) for the costs of covering newly eligible adults under Medicaid expansion from 2014 to 2016. This level of federal assistance was scheduled under Obamacare to phase down to 95% in 2017 and to 90% by 2020 and beyond. Although the version of the AHCA passed by the U.S. House would retain Medicaid expansion, it would provide less generous federal matching funding, beginning in 2020, for new Medicaid enrollees and for existing enrollees who did not have continuous coverage. According to KFF, “A less generous match could mean states would be less willing to cover the new adult population in the years to come and, in fact, several states already have triggers in place to rescind coverage for the current group if the federal match declines to certain levels. It would also provide a disincentive for other states to expand in the future.”
KFF also notes that the AHCA proposes a per capita cap on Medicaid funding to limit federal spending and increase states’ flexibility in the use of Medicaid funds—an approach that could limit health care access for PLWH. “Under restructured and constrained financing, states would probably respond by reducing services or eligibility to accommodate a loss in federal dollars,” according to KFF. “Beneficiaries may see increased cost-sharing and providers, reductions in reimbursement rates. As these programs could be structured in a multitude of ways, it will be important to watch how proposals might impact access to coverage for people with HIV in terms of eligibility, benefits, cost-sharing, beneficiary protections, and enrollment requirements. These proposals to change per beneficiary spending would apply to the HIV disability population in traditional Medicaid as well as the newly eligible expansion population.”
In addition to the changes that the AHCA would make to Medicaid, Section 1115 of the Social Security Act gives the secretary of Health and Human Services (HHS) authority to approve Medicaid experimental, pilot, or demonstration projects. In March, HHS secretary Thomas Price and Centers for Medicaid and Medicare Services (CMS) administrator Seema Verma sent a letter to governors outlining the Trump Administration’s approach to Medicaid policy. The letter indicated that it would consider waivers that include higher beneficiary cost-sharing for state Medicaid programs and that adopt alternative benefit designs, which could include features such as health savings accounts and work requirements—“all provisions that could impact access to care and treatment for people with HIV,” according to KFF.
Proposed changes to the individual insurance market under the AHCA could also have major impacts on PLWH, according to KFF. These include changes in the Obamacare provisions that:
- require insurers to cover pre-existing conditions, prevent them from charging higher rates based on health status, and prohibit them from imposing lifetime and annual limits on coverage;
- provide income-based tax credits and cost-sharing subsidies that help make insurance premiums affordable and limit out-of-pocket expenses for people with low incomes; and
- require that health insurance policies cover 10 categories of essential health benefits.
As described in earlier articles in this newsletter, if the current House version of the AHCA became law, it would eliminate Obamacare’s current income-based tax credits and cost-sharing subsidies, and replace these with tax credits based on age. These age-based credits are much less generous for people who have low incomes, which is the case for many PLWH. The House version of the AHCA would also allow states to obtain waivers that permit insurers in the state to issue policies that lack coverage of essential health benefits or charge higher rates for people with pre-existing conditions, such as HIV.
The federal government also has the capacity to reverse past regulations and create new regulations or modify health policy by issuing sub-regulatory guidance. “Changes to rule making can impact how the ACA is implemented including through benefit design, cost-sharing, oversight, beneficiary protections, and market stability,” KFF notes. “For instance, HHS released a final Market Stabilization rule in April of 2017 that will change continuity of coverage requirements, shorten the open enrollment period, tighten special enrollment periods, loosen Actuarial Value (plan generosity) requirements, and pullback on network adequacy and essential community provider requirements and regulatory oversight. Loosening of the network and essential community provider networks in particular could be limiting for people with HIV as it may mean fewer Ryan White and infectious disease providers in plan networks.”
Implementation of the changes described above would likely increase the importance of the Ryan White HIV/AIDS Program (RWHAP) for PLWH, according to KFF. “Under an ACA repeal, coverage gains that have occurred as a result of the law through the Marketplaces and Medicaid expansion could be lost. It is likely that individuals who lose coverage would return to Ryan White to meet their full HIV care and treatment needs, but it is unclear whether the program would be able to absorb clients into traditional HIV care and treatment with existing resources and without resorting to waitlists. Additionally, Ryan White is not an insurance program and covers only HIV related care so those who have gained insurance coverage and transition back to Ryan White exclusively would face losing access to coverage for other health conditions and emergency services. While the program would still be permitted to assist clients with the cost of insurance, the ability of Ryan White to do so as commonly as it does today without the ACA’s subsidies and rate setting protections is in question since by statute such arrangements must be cost-effective for the program.” The cuts to the HHS budget in the Trump Administration’s proposed HHS budget for FY18 could also impact the RWHAP. “If cuts are realized, the Ryan White Program may not be able to sustain existing levels of service provision, especially if more individuals seek assistance from a program with less funding.”
Proposed Trump budget would cut health programs
The Trump Administration’s Fiscal Year 2018 (FY18) budget proposal includes deep cuts to many health programs, including those providing direct services to persons living with HIV. Shortly after the budget was released in late May, various groups, including the American Association for the Advancement of Science, the Treatment Action Group, and The Fenway Institute, published separate summaries of proposed health and science budget changes, including those expected to impact HIV, viral hepatitis, and tuberculosis (TB). These proposed changes include:
- a $7.7 billion (22%) reduction to research at the National Institutes of Health;
- an $838 million (18%) cut to the National Institute of Allergy and Infectious Diseases, which conducts extensive HIV/AIDS research;
- a 17% funding cut to CDC-funded programs for the prevention of HIV, viral hepatitis, sexually transmitted infections, and TB;
- $59 million in cuts to the Ryan White HIV/AIDS Program; and
- eliminating the Minority HIV/AIDS Initiative (MAI), AIDS Education Training Centers, and Special Projects of National Significance (SPNS)
In addition, the budget would provide flat funding of CDC’s hepatitis prevention programs and continue to limit the use of federal funding to purchase syringes.
- cutting $700 million from the President’s Emergency Plan for AIDS Relief (PEPFAR) and $225 million from the Global Fund to Fight AIDS, Tuberculosis, and Malaria;
- eliminating the Fogarty International Center, which trains scientists around the world in HIV and TB research;
- eliminating U.S. funding commitments for the International AIDS Vaccine Initiative (IAVI) and microbicides research; and
- cutting $62 million from global TB programs at the U.S. Agency for International Development.
Longer-Term Budget Impacts
Looking beyond FY18, The New York Times published an interactive chart, How Trump’s Budget Would Affect Every Part of Government, that has The Times’ projections of federal spending over the next 10 years, based on the Trump budget proposal, compared to projected spending under current policies. These include 10-year cuts totaling $2.02 trillion (28%) to all health programs; $627 billion to Medicaid (a total that does not fully account for the even larger Medicaid cuts under the proposed American Health Care Act); $87 billion to the National Institutes of Health; and $18 billion to the CDC.
Many policy, research, and health care organizations, news agencies, and patient advocacy groups issued statements responding to the Trump Administration’s budget proposal and analyzing its projected impacts. These include a joint statement by AIDS United, the National Alliance of State and Territorial AIDS Directors, the National Coalition of STD Directors, NMAC, and The AIDS Institute. For your convenience, we have provided links to selected other statements and analyses that focus on research and health funding here: American Academy of Pediatrics; American Association for the Advancement of Science; Association of American Medical Colleges; American Public Health Association; AVAC; Health GAP (Global Access Project); Project Inform; Science Speaks; The Fenway Institute; and Treatment Action Group. In addition, the Kaiser Health News daily briefings for May 24 link to numerous news summaries of the proposed FY18 budget proposal in the Administration News section.
Many HIV+ Persons Who Respond Well to Treatment Have Near-Normal Life Expectancy
The overall health of millions of persons living with HIV have improved dramatically in the two decades since effective combination antiretroviral therapy (ART) first became available in the mid-1990s. In recent years, a number of studies have also documented large increases in the life expectancy of some HIV+ persons – especially those who are diagnosed relatively early in the course of infection and who receive treatment promptly. Now a very large study has confirmed that people who respond well to ART during their first year on treatment achieve a near-normal life expectancy.
In the study, a multinational research group known as the Antiretroviral Therapy Cohort Collaborative analyzed data from 18 European and North American cohort studies that tracked the health of nearly 90,000 persons who started ART during different time periods, ranging from 1996 to 2010. In particular, the researchers examined death rates during the first 3 years after people started ART and used that information to estimate future life expectancy. They found that, between 1996 and 2010, the average life expectancy of people receiving ART increased about 10 years for both men and women. For people who started ART between 2008 and 2010 and who were still alive with a CD4 T-cell count over 350 a year after beginning treatment, their life expectancy is similar to that of the general (non-HIV-infected) population. For example, the researchers estimate that a 20-year-old who started and responded well to ART during that period could expect to live, on average, to the age of 78. However, the study shows that, compared to the general population, people starting ART treatment still have an increased risk of death during the first year of treatment – a period when some have low CD4 counts that place them at risk for life-threatening opportunistic illnesses.
It is also worth noting that the overall life expectancy figures are averages and do not mean that all groups benefit equally well. In particular, people who inject drugs and those who start ART with low CD4 cell counts have lower life expectancies than people who do not inject drugs and start ART with higher CD4 counts. Interestingly, the life expectancy benefits of ART were somewhat better in Europe than in North America. The researchers also found that the direct effects of ART – reduced viral load and higher CD4 counts – weren’t the only factors that increased the life expectancies of HIV+ persons receiving treatment. Improved care for other health conditions, such as heart disease, diabetes, and malignancies, also had an impact. The study indicated that, over the years, there were particularly large decreases in the death rates due to heart and liver disease, including hepatitis C (HCV). Since the study included only persons who started ART between 1996 and 2010, it does not provide any information about the additional health benefits people co-infected with HIV drug regimens that have become available during the past few years.
FEATURED HEALTH RESOURCES
Materials for National HIV Testing Day (June 27)
National HIV Testing Day is an annual observance to promote HIV testing in the U.S. The 23rd annual HIV Testing Day will be held on Tuesday, June 27. The theme for the 2017 campaign is “Test Your Way, Do It Today!” To help you, your patients or clients, and at-risk communities prepare for and mark the day, we’ve compiled an annotated list of online resources focusing on HIV testing.
HIV Testing in the United States. Web page from the Kaiser Family Foundation.
HIV Testing 101: Consumer Info Sheet. Easy-to-read fact sheet in question-and-answer format from CDC.
HIV Screening and Testing. Web page from the Centers for Disease Control and Prevention (CDC) with links to many resources, including guidelines for HIV testing in clinical and nonclinical settings, HIV laboratory testing and reporting of test results, and HIV testing of donors of organs and other tissues.
HIV Expanded Testing Initiative. Fact sheet from CDC.
GetTested: National HIV, STD, and Hepatitis Testing. CDC web page that includes a search feature to help people find nearby testing sites.
“I’m Doing It.” CDC has developed an extensive and growing body of materials for this HIV testing campaign, including videos, posters, palm cards, and banners featuring celebrities, community leaders, and volunteers.
*Eric Brus writes about HIV policy. His HIV/AIDS Disparities Report is produced by the New England AIDS Education and Training Center Minority AIDS Initiative Project. The full version is available online.