AIDS Advocates Fear Potential Consequences of ACA Repeal

One of the foremost priorities of President-elect Donald J. Trump and the Republican-controlled Congress will be to repeal the Affordable Care Act (ACA), which expanded Medicaid and prevented insurers from denying coverage based on preexisting conditions. The looming threat of repeal without a specified plan for replacement has some worried that a loss of coverage for patients with HIV and AIDS could lead to increased mortality and transmission rates.

Last month, a coalition of 180 HIV-related organizations sent a letter to Congress warning of the consequences of ACA repeal without a plan in place. The letter, sponsored by the Federal AIDS Policy Partnership’s HIV Health Care Access Working Group, indicated that the strides in HIV prevention and treatment could be undone if patients lose access to care. Prior to the ACA, they wrote, many people with HIV “were denied private health insurance coverage or could not afford the high cost of the coverage available to them.”

Another letter, signed by more than 950 HIV experts, asked Congress to preserve coverage, sustain federal funding of Medicaid, and continue Medicaid expansion. Like the other letter, this one pointed out that many patients in the pre-ACA insurance landscape only became eligible for Medicaid after they had become disabled by AIDS.

The expansion of Medicaid in 31 states and the District of Columbia was cited by a Reuters article as the most significant component of the ACA for people with HIV. Medicaid now covers more than 40% of HIV-positive people, making it the largest source of coverage for this population. HHS has not yet released data on how many of the 1.2 million Americans with HIV have gained coverage under the ACA, but data from Illinois indicated that 1 in 3 people with HIV gained coverage after the state expanded Medicaid. By 2016, the number of Illinois residents with HIV covered by Medicaid had increased by over 50% after the expansion in 2013.

Advocates worry that even if the ACA repeal keeps Medicaid expansion and other individual plans in place for 3 years while a replacement is developed, the delay would destabilize the insurance market and make payers reluctant to commit to individual insurance plans. Without the antiretroviral treatments that suppress HIV viral load, patients would get sicker and the likelihood of transmission to others would increase.

“Safety nets” like the Ryan White federal grant program exist to help the uninsured pay for their insurance premiums and AIDS treatments, but they could run out of funding if the ACA’s repeal causes a sudden influx of patients in need of financial help. In 2011, almost 9300 patients were on waiting lists for AIDS drug assistance programs.

These concerns surrounding insurance coverage of AIDS patients and the public health implications highlight the thorny issues Republicans must contend with as they prepare to unravel the health reform law. Vice President-elect Mike Pence has said that the transition team is “mindful of disrupting the market,” but did not offer information on specific plans for replacement.