Prior to the Affordable Care Act (ACA), low income people living with HIV faced a “Catch-22” regarding Medicaid eligibility: They could not qualify for Medicaid until they were considered permanently disabled, but medications available through Medicaid could help slow disease progression and prevent deadly opportunistic infections. Under the ACA’s new adult Medicaid expansion group, individuals who are HIV-positive can be eligible for Medicaid, and access potentially life-saving medications and treatment services, without having to wait until they receive a full AIDS diagnosis.
A Supreme Court ruling allowed states to decide whether to adopt the new adult Medicaid group, and some states have so far refused despite a 100 percent reimbursement from the federal government for 2014-2016, scaling down to 90 percent in 2016. Currently, only 25 states and the District of Columbia have agreed to expand Medicaid programs to low income adults, including those living with HIV.
In the states that have chosen to forgo the adult Medicaid expansion, low income persons with HIV have limited options for health coverage. Those who make over 100 percent of the federal poverty line may qualify for subsidies provided under the ACA, including premium assistance and help with co-pays. But those who purchase a Qualified Health Plan (QHP) through the insurance marketplaces, may encounter limited drug formularies and high cost sharing which subsidies don’t cover. This could make some HIV treatment medications difficult to access, and as a result people with HIV/AIDS, especially at lower income levels, are likely to experience coverage gaps — which may lead to drug resistance and worsening health outcomes.
These coverage gaps highlight the need for continued funding for federal health programs for people living with HIV/AIDS, including the AIDS Drug Assistance Program (ADAP), funded largely through the Ryan White CARE Act. Under recent guidance from the U.S. Department of Health and Human Services (HHS), states can use ADAP funds to help people with HIV/AIDS with premiums and co-pays when other subsidies fall short. This type of assistance is only available when the QHP has prescription drug coverage equivalent to ADAP.
Currently, states are evaluating QHP drug formularies and comparing them to the state’s ADAP, but this information is not likely to be available to people with HIV who are making their plan selections now. Last month, a coalition of HIV/AIDS advocacy organizations sent a letter to HHS Secretary Kathleen Sebelius outlining these and other concerns regarding ACA implementation.
Despite these concerns, the ACA provides an unprecedented opportunity to provide coverage to people living with HIV. According to a recently released issue brief from the Kaiser Family Foundation, an estimated 200,000 people with HIV could gain new coverage through the new Medicaid expansion for adults or they could gain subsidies to purchase private health insurance through the health insurance exchanges.
This guest blog post was prepared by Wayne Turner, Staff Attorney at the National Health Law Program.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state. The views expressed in this post do not represent those of the Network or the Robert Wood Johnson Foundation.