This month marks two significant moments in the fight against HIV and Hepatitis C in North Carolina. Sadly, as we cheer progress it’s impossible to ignore efforts to repeal the Affordable Care Act and undermine Medicaid, which would hobble efforts to end both of these epidemics.
June 5 was the 36th anniversary of the first AIDS case. Since 1981, we’ve made significant strides toward eradicating HIV. New antiretroviral medications have allowed people to suppress the HIV virus and live long, healthy lives. We also have new tools, like Pre-exposure prophylaxis (PrEP) that can prevent HIV.
We have just started to turn our attention to the opioid epidemic and the increasing rates of Hepatitis C (HCV). On May 31, the Herald-Sun reported that 110,000 to 150,000 people are living with HCV in North Carolina. Fifty percent of these cases are undiagnosed and approximately a third of those living with HIV are also living with HCV.
To properly treat and stop the spread of HIV and HCV, North Carolinians need access to affordable, quality health insurance. The Affordable Care Act, otherwise known as Obamacare, has provided access to health insurance for over half a million North Carolinians.
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The House-passed American Health Care Act and the just released Senate bill threaten key Affordable Care Act and Medicaid tools that help our state combat the HIV and HCV epidemics:
Consumer Protections: Before the ACA, coverage limits cut vulnerable citizens’ insurance just when they needed it most. The requirement that insurance cover essential health benefits eliminated skimpy insurance plans that gave a false sense of security and failed when they were needed most. Both the House and Senate bills allow states to waive essential health benefits and coverage caps.
Affordability: The ACA lowers insurance costs through premium tax credits tied to income and local insurance rates, as well as through reduced copays and deductibles. That cost sharing help is crucial for people with HIV, whose drugs alone can cost over $30,000 a year, and people with HCV, whose cure tops $80,000. Both the Senate and House bills eliminate this much-needed cost sharing help and allow higher deductibles. Both bills purport to lower premiums, but do so by shifting the premium burden to older consumers, increasing deductibles, and potentially decreasing benefits. Older consumers would be expected to pay from 5 to 8 times more than younger. An analysis by the National Academy for State Health Policy shows that under the House bill, a 60-year-old Cumberland County resident earning $30,000/year would see her net premium after tax credit rise from $2480 to $20,710 per year -- 69% of her income. The Senate takes away ACA tax credits from people with incomes between 350 and 400% of the federal poverty level ($41,580-$47,520). Another affordability threat is the Senate’s elimination of the coverage mandate, with nothing in its place. Without a carrot or stick to coax healthy people to buy insurance, expect a “death spiral” when the market attracts mostly sick people and premiums skyrocket.
Pre-existing Conditions: The ACA outlawed insurance discrimination against those with pre-existing conditions, so that people living with HIV and other chronic diseases can now buy coverage with the same terms and rates as everyone else. The AHCA lets states release insurers from this obligation, exposing people to dramatically higher costs and medical underwriting if they have a gap in coverage. A supposed solution is a high risk pool, segregating people with pre-existing conditions so that healthy people get cheaper coverage. North Carolina’s pre-ACA high risk pool was well intentioned, but had inadequate funding, high premiums, waiting periods, and low enrollment, particularly among people living with HIV. It has been estimated that it would cost $496 to $827 billion over 10 years to adequately fund high risk pools in all states, but the AHCA sets aside only $138 billion over 8 years. While the Senate bill theoretically keeps protections around pre-existing conditions, it allows states to waive just about every ACA requirement, so the protection is illusory.
Medicaid: Long before the ACA, Medicaid provided access to care for our most vulnerable kids, seniors, and people with disabilities, now including 7,300 North Carolinians with HIV. The House version of the AHCA goes far beyond ACA repeal and puts Medicaid in the bullseye, not just targeting Medicaid expansion, but reshaping the core Medicaid program and slashing federal support by 25 percent over 10 years. The Senate’s long awaited bill cuts Medicaid even more.
The president has shown little grasp of the health care system, but on one thing, he is right: The American Health Care Act is mean. And the Senate bill is meaner. Sens. Burr and Tillis must put the needs of our state’s residents ahead of politics, and refuse to support any bill that turns back the clock on advances in health coverage under the Affordable Care Act.
Lee Storrow is the executive director of the North Carolina AIDS Action Network. Allison Rice is the director of the Health Justice Clinic at Duke Law School.