Navigating the Affordable Care Act and HIV

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The past year has brought about a great deal of change in health care reform, particularly in the form of new legislation referred to as the Affordable Care Act.  Since this legislation is controversial and uncharted ground, I think it is safe to say that even more change is imminent. There are specific aspects of the Affordable Care Act (ACA) that are still unraveling and health care networks are still responding to many unknowns, but like it or not, the ACA is here to stay. What is important in my office is to recognize the impact that this new legislation has had on how HIV-positive individuals are able to access health care and medications. More important is that anyone who is potentially affected by HIV should seek to be informed about how the ACA will affect their care.

As Utah and the HIV community prepared for pending changes these past few years, agencies such as the Utah AIDS Foundation and Clinic 1A at the University of Utah took the lead in understanding and navigating change brought about by the ACA in order to ensure a continuum of care for patients. The Utah AIDS Foundation created a new program that would allow them to staff multiple health exchange navigators, whose sole function was to help HIV patients find a health care plan that would best meet their needs. Case managers at Clinic 1A are functioning in a similar manner and both agencies have spent a great deal of time strategizing with each other and with insurance liaisons to understand the laws and the system and identifying plans that would best suit the needs of HIV patients.

The upside is that HIV positive individuals are being enrolled in comprehensive health care plans as opposed to being enrolled in a program for HIV related health care only.  This means that patients will have coverage for all health issues, not just their HIV-related health issues. For many years, more than 50 percent of HIV-positive men and women living in Salt Lake County were relying on the federally funded Ryan White Program to pay for their HIV health care. In addition, patients have also been enrolled in a federally funded drug assistance program to help pay for HIV medication. Although these programs have been invaluable to HIV patients who were uninsured, they were limited in that they only covered health care costs and medications related to HIV.

This year, caseworkers are already experiencing problems with patients accessing the medications they prefer and/or have been taking for years. The current law under the ACA, states that the plans have to ensure access to the medications but they do not specify that they have to be the newest generation combination antiretrovirals. As a result, many plans are only agreeing to cover the less expensive and older medications that have to be taken separately.

The HIV community is continuing to recognize that there will be new challenges ahead as more things change. There are patients already who are falling into the “Medicaid gap” which means that they make too much money to qualify for Medicaid under the Affordable Care Act. The “medicaid gap” was a projected problem among many states as the ACA was being implemented, and in order to avoid it, Medicaid expansion monies were offered to states, however Utah declined the funding.

An additional concern for Health Exchange Navigators and case managers,  is the future of Ryan White funding.  Federally funded programs such as Ryan White are expected to receive more cuts moving forward, or may even be phased out altogether due to the ACA. Currently, case managers are using Ryan White monies to pay for the initial deductibles for patients health care plans, so that the HIV patient incurs little to no expense for their care. Deductibles per patient are roughly $3500 and this year Ryan White monies have been used to cover many existing HIV patients, but case workers don’t know what to expect for next year. If this funding is cut or if it goes away altogether, HIV patients will be expected to contribute to the cost of their plans through copays, deductibles and monthly payments.

Lastly, Health Exchange Navigators expect that patients will have to look for new plans every year to ensure the best coverage and to find plans that best meet their needs. This will require going into the exchange yearly, finding the best plan, and learning how to navigate a new health care system every year. At the least this will lead to frustrations, and quite possibly will challenge a successful continuum of care.

When asked by patients about the ACA, I always go back to the intent of the legislation. It is intended to ensure access to health care for everyone, in the most affordable and reasonable manner possible. Many positive changes have occurred as a result of the ACA. People with pre-existing conditions such as HIV cannot be turned away due to that pre-existing condition, nor can they be expected to pay more for a plan due to that condition. And, as I already pointed out, patients are getting enrolled in comprehensive plans that cover all of their health needs, not just their HIV-related health needs. There is, however, an expectation that everyone will need to pay something for their health care, based upon their individual or family income and therefore these costs should be reasonable and affordable to everyone.

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