Senate Version of Health Bill Will Likely Harm People With HIV

As this column was being finished, the U.S. Senate was still working on its version of a bill that would replace the Affordable Care Act. Little is known about the bill, which is being drafted by a small group of Republican senators. No public hearings will be held on the bill before the Senate votes on it.

To pass under the budget reconciliation process, the Senate bill will need at least 50 votes, with Vice President Mike Pence as a tie-breaker in the event of a 50-50 tie. Since there are just 52 Republican Senators and no Democratic Senators are expected to vote for AHCA, any bill developed by the Senate can only afford to lose the votes of two Republican Senators. It is not clear when -- or whether -- the Senate will pass legislation. If they do, then the House and Senate will need to negotiate the differences between the Senate bill and the American Health Care Act, which was passed by the House May 4. That compromise bill will then need to pass both the House and Senate.

The Kaiser Family Foundation (KFF) published a seven-page issue brief, "What Is at Stake in ACA Repeal and Replace for People with HIV?" soon after the U.S. House passed the AHCA. The brief examines the potential effects of different Affordable Care Act (ACA or Obamacare) repeal scenarios and related administrative actions on people living with HIV (PLWH).

It focuses primarily on three main policy areas of particular importance to PLWH: (1) the future of Obamacare's Medicaid expansion; (2) changes to the traditional Medicaid program; and (3) the proposed reforms affecting the private health insurance market, including changes to Obamacare's insurance marketplaces.

Of these policy areas, changes to Medicaid would likely have the greatest impact on people living with HIV, according to KFF. Medicaid is currently the single largest source of health coverage in the U.S. for PLWH, and its role for PLWH has expanded significantly under Obamacare. Before Obamacare took effect, individuals could not qualify for Medicaid based on income alone. Instead, they had to have both a low income and another condition or characteristic -- such as disability, pregnancy, or being parents -- to be eligible.

These eligibility requirements excluded most low-income childless adults from Medicaid coverage, including many low-income PLWH who could not qualify for Medicaid unless they were already sick and disabled, often as a result of developing AIDS. Obamacare changed this by requiring states that expanded their Medicaid programs to cover persons whose incomes were below 138 percent of the federal poverty level (FPL) based on their income and residency status alone -- other conditions or characteristics were no longer required.

By May 2017, 32 states (including the District of Columbia) where an estimated 62 percent of PLWH live had adopted Medicaid expansion. Under Obamacare, the federal government provided those states with 100 percent federal funding (often referred to as matching funds) for the costs of covering newly eligible adults under Medicaid expansion from 2014 to 2016. This level of federal assistance was scheduled under Obamacare to phase down to 95 percent in 2017 and to 90 percent by 2020 and beyond.

Although the version of the AHCA passed by the U.S. House would retain Medicaid expansion, it would provide less generous federal matching funding, beginning in 2020, for new Medicaid enrollees and for existing enrollees who did not have continuous coverage.

According to KFF, "A less generous match could mean states would be less willing to cover the new adult population in the years to come and, in fact, several states already have triggers in place to rescind coverage for the current group if the federal match declines to certain levels. It would also provide a disincentive for other states to expand in the future."

KFF also notes that the AHCA proposes a per capita cap on Medicaid funding to limit federal spending and increase states' flexibility in the use of Medicaid funds -- an approach that could limit health care access for PLWH.

"Under restructured and constrained financing, states would probably respond by reducing services or eligibility to accommodate a loss in federal dollars," according to KFF. "Beneficiaries may see increased cost-sharing and providers, reductions in reimbursement rates. As these programs could be structured in a multitude of ways, it will be important to watch how proposals might impact access to coverage for people with HIV in terms of eligibility, benefits, cost-sharing, beneficiary protections, and enrollment requirements. These proposals to change per beneficiary spending would apply to the HIV disability population in traditional Medicaid as well as the newly eligible expansion population."

In addition to the changes that the AHCA would make to Medicaid, Section 1115 of the Social Security Act gives the Secretary of Health and Human Services (HHS) authority to approve Medicaid experimental, pilot, or demonstration projects. In March, HHS Secretary Thomas Price and Centers for Medicaid and Medicare Services (CMS) administrator Seema Verma sent a letter to governors outlining the Trump Administration's approach to Medicaid policy.

The letter indicated that it would consider waivers that include higher beneficiary cost-sharing for state Medicaid programs and that adopt alternative benefit designs, which could include features such as health savings accounts and work requirements -- "all provisions that could impact access to care and treatment for people with HIV," according to KFF.

Proposed changes to the individual insurance market under the AHCA could also have major impacts on PLWH, according to KFF. These include changes in the Obamacare provisions that: