Thursday, February 13, 2014

Keeping a Watchful Eye on ACA Implementation, and ADAPs

By Anna Meghan Nunn
Intern from the University of North Carolina at Wilmington, Department of Public and International Affairs

The Patient Protection and Affordable Care Act (PPACA), or the Affordable Care Act (ACA) – also known as "Obamacare" – is in the early stages of implementation, but there are emerging uncertainties in the public health community about certain aspects of the law. Specifically, some advocacy groups, nonprofit organizations, advocacy coalitions, and policy institutes have voiced concern over the potential threat the ACA may pose to the HIV/AIDS community. While most in the public health community view the new healthcare law favorably with respect to HIV/AIDS care, there are some unintended consequences that have many worried. Specifically there are five areas of concern about the new law and its potential impact on HIV/AIDS supports and services:

Gaps and barriers in access to comprehensive care and treatment
Unintended consequences
Uncertainties in treatment/coverage
Future of the Ryan White CARE Act
ADAP’s role in the distribution of allocated funds

Affordable Care Act: Millions of Americans Benefiting from the Law

Gaps and Barriers in Access to Comprehensive Care and Treatment
A recent Kaiser Health News article estimated that there are nearly 1 million patients living HIV/AIDS, and whereas the ACA will bring new opportunities for health care coverage to those patients, there will be some gaps in coverage. For example, the Henry J. Kaiser Family Foundation in its recent study, "Status of State Action on the Medicaid Expansion Decision, 2014," indicates that there are currently 19 states opting out of the Medicaid Eligibility expansion offered through the ACA, with 6 states still openly debating the decision. This includes, but are not limited to, the majority of the states in the Southeastern portion of the country. The Southeast also accounts for 8 of the top ten states with the highest HIV/AIDS rates. Patients in these states will see significant gaps in their healthcare coverage, as many of them will not qualify for Medicaid or tax exemptions for private insurance in the Marketplace Exchange. In total it is estimated that 4 million of the lowest income Americans will suffer gaps in coverage due to the states choosing to opt out of the expansion. Further, because the ACA will impact states differently there is concern that some states will suffer more than others. An article published by the Virginian-Pilot entitled, HIV Patients Wade Warily Into the Health Marketplace (2014), emphasizes a major concern in their state. They contend that, “… because of Ryan White funding rules, patients in the drug-assistance program can sign up only for plans that cover all HIV medications included on the program's formulary. Plans from Anthem Blue Cross and Blue Shield of Virginia don't include them all. That means none of the program's clients can sign up for an Anthem policy.” These state-by state cases are causing confusion for programs like the AIDS Drug Assistance Program (ADAP) that are ensured with helping clients find affordable health care coverage and medications.

An additional concern of some advocates is the fact that undocumented aliens will not be covered by ACA insurance and will therefore not benefit from the comprehensive care that would otherwise be available to them. This has considerable negative implications for public health, public clinics, and already over-burdened emergency rooms where these patients will likely be forced to receive their care.

Unintended Consequences 
The unintended consequences of the implementation of the ACA relates to the financial burden it will place on low-income patients living with HIV/AIDS. While many patients are enthusiastic about the potential of more comprehensive coverage, many are concerned about the out of pocket expenses that they may incur through co-pays, deductibles, and further costs associated with laboratory tests and associated costs related to HIV/AIDS care. Currently, ADAP assists with some of these costs including medications. The implementation of the ACA may force many patients to pay these costs until they reach an “out of pocket maximum,” which will potentially take months to reach and place a sizeable financial burden on patients, many of whom are living below the poverty level or on fixed incomes. A New York Times article entitled, On Health Exchanges, Premiums May Be Low, but Other Costs Can Be High (2013), states that, “For policies offered in the federal exchange, as in many states, the annual deductible often tops $5,000 for an individual and $10,000 for a couple.” It is still unknown how many HIV/AIDS patients will be impacted by these large deductibles and co-pays.

Uncertainties in Coverage/Treatment
With the rollout of the ACA still in the early stages there is a great deal of uncertainty in the future of coverage and care for patients living with HIV/AIDS. The ambiguity of the law and the reaction of the states has many worried that certain medications will not be covered. The previously mentioned Kaiser Health Network article also highlights these concerns saying that, “advocacy groups have criticized some health plans in the insurance exchanges for failing to cover key HIV medications, charging high amounts for necessary drugs or failing to tell consumers which doctors and medications are included.”  While this benefits these insurance companies, as they will not be covering the expenses related to patients living with HIV/AIDS, it puts the burden back on public clinics and leaves patients without access to crucial drugs that they need. Further still, many are concerned as to whether or not they will be able to continue seeing their current medical professionals and continue on their healthcare regimens. This is a notable concern due to the importance of the healthcare regimen and could have serious consequences to public health.

The Future of the Ryan White CARE Act
While the ACA will be beneficial for many patients in the country, there is unease among many as to how the law will affect the Ryan White CARE Act. The Ryan White program is funded through federal dollars and some are worried that increased access to healthcare may have inadvertent effects on funding. There may be a political pushback against funding programs like ADAP through federal grants like the Ryan White program. This was recently witnessed in the case of the Farm Bill with Republicans pushing to separate the legislation into two separate Bills in an effort to cut funding to food stamps and lower the price tag of the $939 billion proposal. Some worry that the same may occur with decreased funding for Ryan White or a loss of funding all together. We argue that these funds are still vital and necessary to providing access to medications, insurance plans, supplemental insurance, and associated costs of HIV/AIDS related treatment.

ADAP’s Role in the Distribution of Allocated Funds 
A final concern is the role ADAP will play in the distribution of the Ryan White program funds. It is ultimately going to be up to local programs and health departments receiving Ryan White funds as to how they will be allocated with regard to costs not associated with medications. These costs include co-pays, laboratory tests, and other cost sharing expenditures. There is a great deal of concern as to how ADAP will be able to administer these funds. A similar situation arose a few years ago when many ADAP programs in the southern states had to take drastic measures to reduce their extensive waiting lists. Many of these states were forced to cap enrollment, reduce formularies, discontinue reimbursements of laboratory expenses, and use emergency ADAP funds to reduce the number of patients living with HIV/AIDS on their waiting lists (NASTAD, 2012). It is the concern of ADAP that a parallel incidence will occur with the rollout of the ACA.

It is crucial that the public health community continue to monitor these glitches with the Affordable Care Act and collaborate on solutions to better assist the recipients of ADAP funds.

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