By: Eric Brus*—
In the nearly seven years since the Patient Protection and Affordable Care Act (ACA) was signed into law in March 2010, there have been many unsuccessful attempts led by House Republicans to repeal the ACA entirely, change or eliminate some of its main provisions, or restrict the funding necessary to implement the law. With the inauguration of President Donald Trump and the election of Republican majorities in the House and Senate, proposals to repeal and replace the ACA are now being pursued with renewed energy. However, these efforts are also being met with strong opposition from supporters of the ACA who fear that many people, especially persons with low incomes or chronic conditions, may lose health coverage or be burdened with higher health care costs.
This issue, completed during the first week of the Trump Administration, is devoted largely to recent news about health policy changes expected under President Trump and the 115th Congress. We have also included coverage of the hopes and concerns of proponents and opponents to the proposed changes in U.S. health care—with an emphasis on the impacts of these changes on the care and treatment of HIV and viral hepatitis.
President Trump’s First Executive Order Directs Agencies to Scale Back Parts of the ACA
On January 20, President Trump issued his first executive order, which explicitly states his Administration’s intention to promptly repeal the ACA and directs the heads of federal agencies and executive departments to scale back implementation of the law. In particular, the order states that, “To the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.”
News summaries of the executive order published by Health Affairs, Kaiser Health News, the Associated Press, and elsewhere indicate, however, that its immediate impact may be limited. Since the current healthcare rules under the ACA have already been incorporated into insurance company contracts for 2017, the order may have little effect on coverage this year.
In addition, as of this writing, no high-level political appointees had yet been installed at the Departments of Health and Human Services (HHS), Labor, and Treasury, which have primary authority over the law. President Trump had nominated secretaries for each of these departments—U.S. House Budget Committee Chairman Tom Price (R-GA) for HHS, CKE Restaurants CEO Andrew Puzder for Labor, and Dune Capital Management CEO Steven Mnuchin for Treasury—but none had yet been confirmed. Once the heads of these agencies are confirmed, the agencies will need time to develop policies implementing the executive order.
Republican members of Congress broadly support President Trump’s intention to repeal the ACA. However, their views on which parts of the ACA should be replaced, modified, or retained vary widely, as evidenced by the differing provisions of the healthcare proposals that Republicans have floated before and after the 2016 election. (See additional coverage of these proposals in the article below.) Negotiating, reaching consensus, and passing comprehensive healthcare legislation to replace the ACA will likely take considerable time. ACA advocates are expected to fight hard to retain the law or, failing that, some of its key provisions, such as coverage for pre-existing conditions and premium subsidies for low- and middle-income persons.
Finally, assuming a new healthcare law is passed, new regulations implementing the legislation cannot be issued immediately. They must follow an established process that requires a period of public notice and the opportunity for interested parties to comment on the proposed regulations before they become law. In fact, one of the provisions of Trump’s executive order explicitly acknowledges this: “To the extent that carrying out the directives in this order would require revision of regulations issued through notice-and-comment rulemaking, the heads of agencies shall comply with the Administrative Procedure Act and other applicable statutes in considering or promulgating such regulatory revisions.”
HIV Medical Professionals Urge Congress to “Do No Harm” in Efforts to Repeal the ACA
On January 3, a group of more than 950 medical professionals sent an open letter to members of Congress urging them not to repeal the Affordable Care Act (ACA) without first establishing a viable replacement plan that will continue to offer affordable coverage to those eligible under the ACA, and to sustain the federal commitment to the Medicaid program. The letter was signed by members of four HIV medical groups: the HIV Medicine Association (HIVMA), American Academy of HIV Medicine (AAHIVM), Association of Nurses in AIDS Care (ANAC) and the Ryan White Medical Providers Coalition (RWMPC).
The letter states that, “Prior to the Affordable Care Act, a majority of our patients [living with HIV] were either denied health insurance coverage because of their condition or were unable to afford the extraordinary high cost of the coverage available to them. In most states, Medicaid coverage was available to patients only after they became sick and disabled by AIDS.
The ACA leveled the health care playing field by barring plans from denying coverage or charging higher premiums based on health status, setting minimum health coverage standards, and providing premium and cost sharing assistance. Importantly, it modernized the Medicaid program by expanding coverage to families and childless adults up to 138% of the federal poverty level regardless of disability status.” The medical professionals strongly recommend that any changes to the ACA be grounded on three key principles:
- “Do no harm” by fully taking into account “the medical needs of low income individuals with complex conditions, like HIV, to avoid dangerous disruptions in healthcare coverage for our patients with HIV and millions of others. Meaningful health insurance coverage options must offer uninterrupted, affordable coverage for a range of necessary medical services, including prescription drugs, preventive services, laboratory testing, and substance use and mental health treatment.”
- “Sustain the federal commitment to the Medicaid program. Maintaining the current funding structure, including the federal entitlement, to the Medicaid program is critical so that states can respond to fluctuations in the demand for Medicaid coverage due to economic downturns, public health outbreaks such as the HIV and hepatitis C outbreaks in Scott County, Indiana, and medical advances, such as the recent development of curative hepatitis C treatment.”
- “Continue Medicaid expansion. In the 32 states (including the District of Columbia) that have expanded Medicaid, our poorest patients were offered access to comprehensive, affordable coverage with consumer protections tailored to their socioeconomic and medical needs. Withdrawing this coverage will threaten the health of millions of Americans and be a significant setback to our nation’s public health, including to our efforts to end AIDS.”
OTHER NEWS REPORTS AND MATERIALS
Lancet Paper Examines What Trump Presidency May Mean for Global Health
In a recent paper published online in The Lancet, three British and U.S. health policy analysts provide a scorecard for evaluating the potential impact of a Trump presidency and its expected policies on global health. The scorecard, which draws on the health-related components of the United Nations’ 17 Sustainable Development Goals, “can form the basis of a system to monitor and hold accountable global health leaders,” according to the analysts. The system uses colors to categorize the level of risk of particular policies to health, with green indicating a low risk, amber a medium risk, and red a high risk. Based on their review of the statements that President Trump has made before and after his election, his nominations for key administration positions, and the level of Congressional support for specific policies, the analysts have developed a preliminary scorecard anticipating the Trump Administration’s impact on global health. The scorecard includes the following policy areas that can have a significant global health:
- universal health coverage;
- evidence-based health policy;
- reproductive health;
- vulnerable populations;
- security and foreign policy;
- aid and global health;
- climate action;
- trade and market integration;
- employment and job insecurity;
- social determinants of health and health inequalities; and
- gun violence.
For quick reference, the analysts provide a color–coded summary of their scorecard, together with a more detailed review in the full article. The analysts identify reasons for concern in each of the 11 policy areas – categorizing the risk of possible Trump policies as high in seven areas and medium in four. They note, however, that “We do not see this scorecard as being definitive, and indeed it cannot be until there is greater certainty about what policies will be pursued, but we offer it as a basis for further discussion.” They conclude by urging public health professionals and organizations to play an active role in shaping policy that promotes health and reduces health inequalities.
NIH Launches First Major Trial of a Long-Acting HIV Prevention Drug
The first major clinical trial of a long-acting injectable drug for HIV prevention (HPTN 083) began late last month. The study, which is sponsored by the National Institutes of Health (NIH), will evaluate whether the antiretroviral drug cabotegravir, injected once every 8 weeks, can safely protect men and transgender women from HIV infection at least as well as Truvada. Truvada, a once-daily pill that contains two antiretroviral drugs, is currently the only regimen that has been approved for HIV preexposure prophylaxis (PrEP). The study will enroll 4,500 men who have sex with men and transgender women who have sex with men at 45 sites in eight countries in the Americas, Asia, and Africa. To be eligible for the study, participants must be at least 18 years old and at high risk for HIV infection. Results from the trial are expected in 2021. If injectable cabotegravir is found to be effective for HIV PrEP, it may be easier for some people to adhere to than daily oral Truvada. “We urgently need more HIV prevention tools that fit easily into people’s lives,” noted Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “Although daily oral Truvada clearly works for HIV prevention, taking a daily pill while feeling healthy can be difficult for some people. If proven effective, injectable cabotegravir has the potential to become an acceptable, discreet, and convenient alternative for HIV prevention.”
FEATURED HEALTH RESOURCES
National Black HIV/AIDS Awareness Day (February 7)
National Black HIV/AIDS Awareness Day (NBHAAD) is being observed this year on Tuesday, February 7. As has been the case for the past several years, the theme for NBHAAD in 2017 is: “I am My
Brother’s/Sister’s Keeper: FIGHT HIV/AIDS!” According to NBHAAD organizers, the primary purpose of the event is to encourage Black Americans to:
- Start talking – learn the facts about HIV and AIDS;
- Get tested for HIV;
- Protect themselves and their partners through HIV prevention; and Get treated and remain in care if they are already living with HIV.
To help you and your patients or clients prepare for and mark NBHAAD, we have compiled an annotated list of online resources focusing on HIV/AIDS in the Black/African American community.
Fact Sheets and Reports
CDC report includes detailed information about HIV and AIDS cases and deaths among Blacks/African Americans and other racial/ethnic groups. Breakdowns are also provided by age, gender, HIV transmission category, and geographic region.
Black Americans and HIV/AIDS. This three-page fact sheet from the Kaiser Family Foundation was last updated in 2014. It provides detailed information on HIV/AIDS among Black Americans in the following topic areas: snapshot of the epidemic, key trends and current cases, women and young people, gay and bisexual men, HIV transmission, geographic distribution of cases, access to and use of health care, HIV testing, and opinions about HIV/AIDS.
*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.