The ACA makes a measureable difference with HIV coverage

People with HIV experienced significant coverage gains under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) as a result of Medicaid expansion, the creation of the health insurance marketplaces, and the elimination of pre-existing condition exclusion. According to a Kaiser Family Foundation (KFF) Issue Brief, as long as the future of the ACA remains uncertain, those access and coverage gains are at risk.

Baseline

To develop a baseline for understanding current access to care for people with HIV, KFF examined multiple variables across the three main pathways for HIV coverage and care: (1) Medicaid, (2) private insurance and the ACA marketplace, and (3) the Ryan White HIV/AIDS program. KFF considered factors like states’ Medicaid expansion status, the number of health insurance issuers per county, and AIDS Drug Assistance Program (ADAP) eligibility levels.

Medicaid 

Prior to the ACA’s Medicaid expansion, most individuals with HIV obtained Medicaid coverage through the disability pathway, meaning that coverage was often not obtained prior to a beneficiary’s development of AIDS. Currently, 62 percent of people with HIV live in a Medicaid expansion state, where care is more likely to be accessible through the income pathway, regardless of disability level. Additionally, 24 states provide Medicaid coverage through the disability pathway above the federally mandated level of 73 percent of the federal poverty level (FPL).

Marketplaces 

In 33 states, where 83 percent of people with HIV live, there are three or more issuers in the ACA marketplace. While five states—Arkansas, Oklahoma, South Carolina and Wyoming—had only one issuer in 2017, some states had several. For example, Wisconsin had 15 insurers, New York had 14, and California had 11. KFF also looked at issuer representation in counties with high incidence of people with HIV. While 43 percent of people with HIV live in one of the eighteen (18) states with an average of three or more issuers per county, the majority of people with HIV—57 percent—live in one of the 33 states with less competition—one or two issuers per county.

Ryan White

The Ryan White HIV/AIDS Program provides outpatient HIV care and treatment to low and moderate income individuals. The program serves more than half of the people diagnosed with HIV in the country. The average eligibility level for the medication assistance program is 386 percent FPL. While 17 states use an eligibility level of 400 percent, 72 percent of people with HIV live in a state with eligibility levels at or above the national average. While the Ryan White program would continue to operate with an ACA repeal, many individuals currently covered by marketplace or Medicaid plans would likely turn to the program for coverage. Due to the program’s limited resources, KFF estimates that such an over-reliance could cause individuals to lose access to care.

CMS grants New Hampshire Medicaid funding compliance extension

CMS has clarified that New Hampshire’s Medicaid expansion may end next year, but the current program can continue until the end of 2018. CMS stated that New Hampshire’s use of voluntary donations from health care providers and hospitals in the New Hampshire Health Protection Fund fails to comply with the federal requirements. CMS raised the possibility that federal funds may be withheld which would have resulted in a termination of the program.

The Medicaid statute in Section 1903(w) of the Soc. Sec. Act and implementing regulations at 42 CFR Sec. 433.54 and 433.66 establish a prohibition on provider-related donations, except in very limited circumstances. In a letter to New Hampshire officials, CMS indicated that there is a relationship between the donations and Medicaid payments, because Medicaid expansion is conditioned on the receipt of donations as articulated in New Hampshire legislation. The state’s use of voluntary donations from hospitals to supplement federal Medicaid funding violates federal law. The non-federal share financing of the New Hampshire Health Protection Program or Medicaid expansion through the use of provider-related donations to pay for Medicaid service-related costs violates the requirement that a bona fide provider-relation is a donation that has no direct or indirect relationship to Medicaid payments.

The 50,000 New Hampshire residents participating in the Medicaid expansion will not see any change in their coverage through the current re-authorization which continues until the end of 2018.New Hampshire’s next legislative session will need to address compliance with the federal law for the 2019 budget to bring the state’s non-federal share financing into compliance with the existing federal statute and regulations. Otherwise, Medicaid expansion in the state will lose federal funding. Governor Chris Sununu (R) stated that stripping coverage from Medicaid enrollees would have been “grossly unfair,” and will use the transition period to consider future changes.

Senate urged not to proceed with BCRA by civil and human rights groups

One hundred sixty six civil and human rights organizations including The Leadership Conference on Civil and Human Rights, the National Health Law Program, and the National Partnership for Women & Families are urging senators to oppose the motion to proceed on the Better Care Reconciliation Act (BCRA) (H. R. 1628). The organizations sent a letter to senators on July 24, 2017, expressing their concern that the BCRA will “eliminate affordable quality health care for millions of Americans.” Specifically, the organizations said that the BCRA would gut the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and slash federal funding as well as transform Medicaid [funding] into a block grant or per capita cap; and eliminate Medicaid expansion (see ACA sec. 2001 and sec. 1201 of the Health Care Education and Reconciliation Act of 2010 (HCERA) (P.L. 111-152). In addition, the organizations pressed senators to support the Parliamentarian’s ruling excluding the defunding of Planned Parenthood from the bill.

The Senate’s lack of transparency

The organizations noted that they were “seriously concerned about the lack of transparency of the discussions’ that lead up to the introduction of the BCRA and “the rush to vote on the bill without adequate time for analysis, hearings, and a discussion of a CBO [Congressional Budget Office] score.” The organizations stressed that such discussions, would allow the public to better understand the proposed legislation and participate in a discussion of their access to health care.

The impact of the BCRA

The organizations identified the issues that arise from the BCRA provisions that the organizations believe would have a serious impact on the communities that they represent including low-income families and people of color. These issues include:

  • The 15 million people that would lose their Medicaid coverage by 2026 under the revised version of the BCRA, as estimated by the CBO.
  • The repeal of Medicaid expansion, which will disproportionately affect the communities including Latinos, African Americans, Native Americans, Asian Americans, Native Hawaiians, and Pacific Islanders who have seen the largest gains in coverage under the ACA, and women.
  • The proposed cuts that could vastly reduce access to needed health care, reduction in needed services, increased medical debt, and persistent racial disparities in mortality rates.
  • The possible reduction in home and community-based services, which are cost-effective and keep individuals out of nursing homes and institutions.
  • The imposition of a work requirement as a condition of eligibility, which fails to further purpose of providing health care and undermines the objective.
  • The defunding of Planned Parenthood that would prevent more than half of its patients from getting affordable preventive care, including birth control, testing and treatment for sexually transmitted diseases, breast and cervical cancer screenings, and well-women exams.

Vanita Gupta, president and chief operating officer of The Leadership Conference noted that the letter reflects the widespread concerns of people, especially people of color, women, and low-income families, who currently “receive life-saving coverage because of the Affordable Care Act and the expanded Medicaid coverage” but will lose their access to quality affordable health care and will have higher health care costs “if the Republicans succeed.”

Economic, job losses predicted with BCRA

The Better Care Reconciliation Act (BCRA), the Senate alternative to the American Health Care Act (AHCA), would lead to significantly larger job losses and reductions in states’ economies by 2026, if passed into law. Both bills seek to partially repeal and replace the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). According to an issue brief by the Commonwealth Fund, both the draft BCRA and the AHCA, which passed the House earlier (see The AHCA strikes back, May 4, 2017), would have similar effects on the number of uninsured Americans. The Congressional Budget Office (CBO) estimated that this draft version of the BCRA would lead to 22 million fewer insured Americans by 2026, roughly the same as the 24 million uninsured estimated for the AHCA (see BCRA would curb Medicaid spending growth, increase uninsured numbers, Health Law Daily, June 30, 2017; Revised AHCA costlier with same number of uninsured, Health Law Daily, March 24, 2017).

The issue brief noted that, generally, federal health funds are used to purchase health care, with fiscal effects from these purchases spreading throughout the rest of the economy by creating jobs and other economic growth. Federal health funds pay hospitals, doctors’ offices, and other providers; these facilities use revenue to pay their employees and buy goods and services, such as rent or equipment. In turn, health care employees or other businesses (and eventually their workers) use their income to purchase consumer goods like housing, transportation, or food. An analogous effect is when federal taxes are reduced, the expectation is that consumers or businesses retain income and purchase goods and services, invest, or save.

Impact on jobs

The Commonwealth Fund noted that Medicaid expansion states would be hardest hit under the BCRA. In terms of job creation or losses, the proposed BCRA would add over 750,000 jobs in 2018, but employment would then deteriorate. It is projected that in 2026, under the BCRA, there would be 1.45 million fewer jobs with the health care sector bearing the brunt of the losses at over 900,000 fewer jobs. State coffers would be reduced by $162 billion.

BCRA would repeal a number of taxes along with a phase-in of coverage-related spending reductions, including Medicaid. The tax repeals would increase federal deficits by more than $50 billion in 2018 and 2019. However, as noted, the number of jobs outside of the health care sector in 2018 would rise. Health care sector jobs would fall immediately with the loss of 30,000 jobs.

By 2026, 1.45 million fewer people would have jobs. Additionally, gross state products would drop by $162 billion and business output would be $265 billion lower, while overall 919,000 jobs would be lost in health care. The issue brief estimated that more than 534,000 jobs in other sectors, including construction, real estate, finance, retail trade, and public employment, would be lost by 2026.

States that expanded Medicaid were estimated to have deeper and faster losses. Having earned more federal funds under the ACA, these states lose more when Medicaid matching rates are cut. In addition to cutting funds to states that expanded health insurance for low-income Medicaid populations, BCRA also increases funding to states that did not expand Medicaid. Nonetheless, the issue brief noted that states that did not expand Medicaid, like Florida and Maine, would also experience job and economic losses after a few years. For instance, Florida would have the sixth highest level of job loss in the nation by 2026.