In hours, the US House of Representatives is set to vote on the American Health Care Act (AHCA), House Speaker Paul Ryan’s plan to replace the seven-year-old Affordable Care Act (ACA). In touting the AHCA, also known as “Trumpcare,” Ryan has claimed that it “will strengthen Medicaid so that states have the tools they need to take care of their poor and most vulnerable populations at a lower cost.”
That’s not quite what we found when we examined how the AHCA would impact lesbian, gay, bisexual, and transgender (LGBT) people and people living with HIV (PLWH)—two of the nation’s most “vulnerable populations,” at least as measured by health and health outcomes.
The changes to Medicaid proposed by the AHCA would put many people with HIV at risk of losing access to life-saving medicines and treatment. Medicaid is now the largest source of health insurance coverage for people living with HIV. Between 2012 and 2014, when the voluntary expansion of Medicaid funded by the ACA was implemented in 26 states, the percentage of people with HIV receiving their health insurance from Medicaid increased from 36 percent to 42 percent. That’s due in large part to Medicaid eligibility changes implemented by the ACA that permit people with HIV to enroll; previously, with the exception of just a few states, people with HIV who were not otherwise eligible for Medicaid would need to wait until their disease progressed to AIDS to qualify for Medicaid. This penny-wise, pound-foolish policy contributed to the spread of HIV as people with untreated HIV have high viral loads that make it much easier for them to transmit the virus to others. Additionally, AIDS is a much more complicated and expensive disease to treat than HIV.
Trumpcare would also reverse ACA-related changes to Medicaid eligibility that have benefitted LGBT people. Previously, only low-income adults with dependent children or low-income adults with a disability were eligible for Medicaid. Now people are eligible for Medicaid on the basis of income alone. Since many LGBT people do not have children, this change has made it easier for them to enroll in Medicaid. In fact, the Center for American Progress has estimated that this change alone has allowed approximately 386,000 previously uninsured low-income LGBT people to access health insurance in the states that have expanded their Medicaid program under the ACA.
Perhaps unintentionally, the Medicaid eligibility restrictions put in place under the AHCA would reward low-income people with HIV who opt to stay on Medicaid instead of accepting higher wage employment. Under the AHCA, in 2020, low-income people would need to be either disabled or have dependent children to be eligible to enroll in Medicaid. A low-income person with HIV who does not have dependent children would need to carefully weigh the risks to their health insurance coverage by accepting a higher paying job. That is because once that person leaves Medicaid, they would not be able to come back. So if that person accepted a higher paying job and then was laid off two years later, the loss of health insurance would be potentially catastrophic if they were unable to quickly find another job. That’s because they cannot afford to go without HIV medication without risking serious complications to their health.
One other Medicaid change under the AHCA that would have potentially devastating consequences for on-going efforts to fight HIV is that AHCA would only reimburse state Medicaid spending based solely on the number of enrollees in the program. If costs unexpectedly go up, which happens when a state responds to public health crises, federal funding would not also increase. In 2014 and 2015 we saw just how expensive—in terms of health care costs as well as human suffering—an outbreak of HIV can be. That’s when nearly 200 people in a rural Indiana county become HIV positive through the sharing of intravenous needles and then-Gov. Mike Pence declared a public health emergency. Under the AHCA, Indiana would not have received additional federal funding for Medicaid even though the costs related to treating nearly 200 people newly infected with HIV resulted in hundreds of thousands of dollars of additional Medicaid costs to the state.
As the country continues to grapple with the opioid epidemic and its attendant complications, which includes increased transmissions of HIV and hepatitis C, the AHCA’s hard limit on resources for Medicaid is the exact opposite of what is needed.
Tim Wang, MPH, is LGBT Health Policy Analyst for The Fenway Institute at Fenway Health. Sean Cahill, PhD, is Director of Health Policy Research for The Fenway Institute at Fenway Health. They are co-authors of the recently published policy brief, What the American Health Care Act means for LGBT people and people living with HIV.