The Patient Protection and Affordable Care Act (aka ObamaCare)

Why saving the ACA is crucial for LGBT communities and those affected by HIV/aids

By:  Al Ballesteros, MBA

The new Trump administration is committed to “repeal and replace” for ObamaCare or the Affordable Care Act which guarantees health care coverage to tens of millions of Americans.  The Republicans have been trying to repeal this law since it went into effect and now that they have control of all branches of the government, it is likely that their efforts will be more successful.  President Trump has installed Secretary Tom Price who has been against the health care law as it exists for many years as a member of the U.S. Congress.  Now that Secretary Price is directing the Health and Human Services Department he has great power to cut away at the law and all the benefits it offers while the Congress comes up with a replacement law.  Republicans ran on a platform to replace the law with something more affordable, “better” and one which would provide more access to more people.  We are still in “wait and see” mode, but existing information available to us in plans such as “A Better Way”, Speaker Paul Ryan’s blueprint signals that the administration maybe considering changes which will truly hurt our community.

Background: The Patient Protection and Affordable Care Act, the ACA was signed into law in March 2010.  The ACA required most individuals to acquire health insurance beginning on January 1, 2014.  There are primarily two mechanisms for individuals to acquire coverage.  Poor people can access care through Medicaid for free and those above the income guidelines can purchase low-cost insurance in the Insurance Market Places.  Some states expanded their Medicaid programs and other states did not.  So, the poor were not all helped in this act and it was not because of the short coming of the ACA.  It was because Republican Governors against the ACA did not expand their programs for the poor.

California did expand Medi-Cal for Poor People under the ACA:  California did expand its Medicaid program called Medi-Cal for low-income people with incomes under 138% of the Federal Poverty Guidelines.  So, currently in California any single adult that is a permanent resident and has an income at $16,243 or below qualifies for free health benefits.  This is roughly $1,353 per month for a single person.  For a family of three, the annual amount is $27,725 or $2,310 or less.  When you consider these incomes, these annual amounts are not much to live on considering the expense of housing, food, gas and other living expenses in California and Los Angeles County.

Los Angeles and California stands to lose a great deal if the Affordable Care Act is repealed:  In Los Angeles County, more than 1 million people qualified and receives healthcare benefits as a result of California’s Medi-Cal expansion under the ACA.  This is a lot of people that now have access to primary medical care, specialists, dental and optometry services, medications, mental health, substance abuse treatment and hospitalization should they need it.  In California, about 3 million people are receiving Medi-Cal as a result of the Affordable Care Act.  If the Republicans repeal the law and cut this Medicaid expansion out, California could stand to lose upwards of $20 billion annually (LA Times, December 21, 2016).  In Los Angeles County, about 500,000 persons bought insurance under the Health Insurance Exchanges, meaning they were not poor enough to quality for Medi-Cal and purchased plans under the Exchanges and are receiving subsidized insurance coverage.  In California, this number is estimated at 1.4 million people.  All of this is at risk when we hear “repeal”.

How does this benefit you and your loved ones?  Health Care Coverage is now guaranteed even for those with Pre-Existing Health Conditions like Cancer, HIV, AIDS and Hepatitis and those that are poor (in most places).  Your Coverage can not be dropped if you get sick and “too expensive” for the Insurance Companies.  Also, dependent children can remain on their parent’ health insurance coverage up to the age of 26.  All new health plans must cover preventive care and important medical screenings and there are no annual or lifetime dollar limits on most benefits to be received.  Under the law, health insurance companies must justify premium increases and may only increase one time per year.  Qualifying for Medi-Cal guarantees coverage for anyone regardless of the medical condition simply based on income.

Why the ACA is very important to the Gay community?  The LGBT and HIV positive communities have a lot to lose if the ACA is repealed.  Prior to 2014, substantial numbers of uninsured persons were people with HIV and LGBT persons.  Numerous health studies have documented that the LGBT community suffers from higher numbers of persons who are uninsured due to discrimination, substance use problems, mental health conditions and health conditions including HIV/AIDS.  Since the beginning of the epidemic substantial numbers of gay, bi men, women at-risk and transgender people became infected with HIV simply because they were poor and uninsured and lacked access to health resources that could have helped them remain HIV negative.   Access to regular and on-going affordable health care is perhaps our best strategy at HIV prevention and the Affordable Care Act accomplished this.

Had the Affordable Care Act been in place at the time HIV was beginning to rapidly spread, the epidemic would have never expanded as much as it did in the United States and among poor, minority communities.  Just take a look at three of the largest states which did not expand Medi-Caid coverage for poor people:  Texas has as many as 1.86 million poor people eligible for health care under the Affordable Care Act; Florida has as many as 1.253 million people eligible and Georgia has many as 682,000 eligible (FamiliesUSA, 1/12/2016).  There are large numbers of LGBT people in these states that are poor and uninsured.  As a result of their Governors (largely Republicans) not increasing Medicaid access for the poor, LGBT communities are suffering the consequences.

In the aforementioned three states, HIV diagnoses had either increased or had no changes in the numbers of annual new infections identified since the Act went into place.  In fact, 4,426 infections were identified in Texas in 2014 vs. 4,491 infections in 2015.  Florida identified 4,587 infections in 2014 vs. 4,864 infections in 2015, and Georgia identified 2,265 infections in 2014 vs. 2,386 infections in 2015.  Compare these numbers to California where the number of HIV infections diagnosed actually dropped from 5,063 in 2014 to 4,728 in 2015.  The same trend is shown for the state of Illinois where infections identified dropped from 1,520 in 2014 to 1,476 in 2015.  (Source:  HIV Surveillance Report, Volume 27, Diagnoses of HIV Infection in the United States and Dependent Areas, 2015)

Why the ACA is Critically Important to populations with HIV/AIDS in Los Angeles and California?  Tens of thousands of people with HIV and AIDS in California received coverage via Medi-Cal expansion as a result of the ACA.  In fact, in Los Angeles County alone, estimates are between 16,000-19,000 poor people with HIV disease gained coverage under Medi-Cal expansion.   Prior to the ACA, these same people did not have guaranteed health care.  There were substantial challenges for many to acquiring adequate care.  This was due to medical insurance being too expensive, offering very little for the cost and largely denying coverage to those with pre-existing conditions.  Prior to the Affordable Care Act, people living with HIV disease who were uninsured and low-income did not automatically qualify for Medi-Cal as HIV by itself did not qualify a person for coverage under the California Medi-Cal program.   Our community had to rely on grants to organizations in Los Angeles County through the Ryan White Care Act which were always limited and never guaranteed on a year to year basis.  Luckily, Los Angeles County did receive substantial grants and this did provide a certain level of care.

But make no mistake about it:  There is a substantial difference in what is available today vs. what was available before the Affordable Care Act for people with HIV disease.  Today, poor people with HIV have guaranteed Health Care Coverage and this was not the case before.   This is includes medical care, access to the latest approved HIV drugs, specialists and hospital services.

Our Ability to Control HIV Infection via PrEP and other Prevention efforts is at risk with repeal of the ACA.  PrEP the bio-medical strategy that is successful in preventing HIV infection is at-risk under an ACA repeal.  This is because if Medicaid is cut California will lose billions of dollars in federal support and would likely not be able to cover the number of poor people it does today.  And, this would largely be people in minority communities where the number of infections is still growing.  Medicaid expansion provides PrEP services to the poor and access to PrEP would be limited if benefits for poor people at-risk of HIV infection are cut.

The Republican leadership has signaled they wish to substantially reduce the amount that the Federal Government provides to the states to cover the poor through the Medicaid program.  Should this happen, many believe states would be forced to cut either eligibility or benefits to the poor.

How our system has change because of the ACA and what would happen if it was repealed?  Prior to 2014, there were fewer outpatient primary care clinics serving LGBT people in medical homes other than those that concentrated on HIV/AIDS.  So our community had a system for the “sick”.  The ACA allowed for the creation of LGBT specific clinics and those within larger organizations which focus on LGBT health as a result of tens of thousands in our community gaining coverage via Medi-Cal and plans in Insurance Market Place.

Several of these organizations are listed in our Medical Resources section on pages 38 and 39.  Repeal of the ACA will lead to fewer LGBT specific health care organizations with the ability to tailor services to our needs because many will lose coverage.  In the long term, our communities’ overall ability to take care of our own needs will be hindered with the repeal of the ACA.  Unfortunately, we’ve never been able to rely solely on the larger system of care to tailor services to meet the needs of LGBT people.

Repeal of the ACA will lead back to a system of care which did not work:  Looking back to the way care was delivered before the ACA, if a person had insurance through their jobs they were lucky.  Unfortunately, many small businesses did not offer insurance because group plans were exceedingly expensive.  The lucky that had insurance through their jobs, were able to access care in mostly private medical clinics.

The uninsured in California were mostly served in the County system of care and experienced long wait times to see physicians and medical specialists.  Because of the high cost of insurance and the lack of access for the uninsured, people waited until they got sick and often ended up in emergency rooms for conditions which could have been prevented had they caught the problems earlier.   Access to care in the emergency room and in a hospital setting is very expensive.  Ultimately, the care for those that access services in the emergency room is offset by higher premiums and coverage payments for the uninsured billed to the state and the federal government.

So, the care is ineffective and more expensive and repealing the ACA will lead us back to this situation once again.

We need to fight to protect the ACA and Medicaid Coverage for the Poor:  Prior to the election of Donald Trump and this push by the Republicans to repeal and replace the Affordable Care Act, I truly believed we in California and Los Angeles were on track to end HIV as we know it.  First, because treatment works to control the virus in one’s body; when the virus is controlled in one’s body, that person is less likely to transmit the infection to others.  One of the biggest barriers to getting control of one’s infection was Insurance Coverage.  Therefore, the ACA solved that problem for thousands.   Not only are tens of thousands of people in California and Los Angeles County healthier, but, our transmission rates are down and I attribute a lot of this to the ACA and the resources this brought to our community.

Second, among the best HIV prevention strategies is access to Regular Health Care and a Medical Home.  The Affordable Care Act and Medicaid coverage helped achieve this for tens of thousands of gay and bi men in poor communities.  Access to regular health care includes access to prevention and testing, health education and information to help one control and reduce their risk. This goes away for tens of thousands of gay and bi men and transgender persons with the repeal of the ACA.

Third, prevention with PrEP which is just now ramping up strongly will be severely hindered if the ACA and Medicaid Expansion are repealed.  Our community has not had enough time to implement this strategy and get to critical levels of engagement of at-risk gay and bi men, transgender persons and women at risk.  So, the dream of control of HIV infection via bio-medical prevention strategies becomes lost with an ACA expansion.  Finally, our community has lost so much as a result of poor access to health care and tens of thousands of lives because of this on-going epidemic.  This article has not even adequately spoken to the other needs of our communities in the area of mental health access, women’s health and substance abuse care which would be lost for poor people under an ACA and Medicaid repeal.

What to do:  If you believe in Health Care insurance for all, regardless of one’s financial position, then we need to fight for the ACA.   If you believe that our LGBT community deserves access to health care, regardless of a pre-existing condition, then we need to fight for the ACA.  If you believe HIV has taken a dreadful toll on our community and that we can soon end HIV transmissions, then we need to fight for the ACA.

How to Fight for the ACA:  Here are my suggestions.  Post to the Facebook Walls of:  Representative Paul Ryan our Speaker of the House; Kevin McCarthy, U.S. House of Representatives Majority Leader; and Senate Majority Leader, Mitch McConnell.  Ask them to save the ACA.  Post to the Facebook wall of President Donald J. Trump or jam his twitter account with requests to save the ACA.  If you have a lot of time and are on your computer a lot, post to the walls of as many republican elected officials as possible and make your concerns known.  Post to their Twitter accounts as well.

Make phone calls to Senator Dianne Feinstein 202-224-3841; Call Senator Kamala D. Harris at 202-224-3553.  Join rallies supporting the ACA and Health Care for all.  Register to vote and ask your friends and families in areas in and outside of California to register to vote.  Then vote in 2018 for those who support Health Care Coverage for all and those that support our issues as a community.  You can go on line in your state and register.