Friday, July 17, 2015

ACA Marketplace Insurance Plans: The Good, the Bad & the Ugly

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

The Patient Protection and Affordable Care Act (PPACA), or the Affordable Care Act (ACA) – also known as Obamacare – has provided a tremendous opportunity for people living with HIV/AIDS to better access linkages to care and treatment. The total number of uninsured Americans has dropped approximately 6 percent since the law's enactment[1], although it is unknown how many people living with HIV/AIDS are included in that number because specific data is hard to come by (surprise, surprise).

Anyone interested in diving into some of the available data might want to read the analysis prepared by John S Kiernan, whereby he compared the rates of the uninsured by State before and after Obamacare.[2] The data used to compile this report is courtesy of the Kaiser Family Foundation, the Centers for Medicare and Medicaid Services, the Department of Health and Human Services, and the U.S. Census Bureau.

Figure 1. Main Findings: Uninsured Rankings

Source: WalletHub

Unfortunately, not everything with Obamacare's implementation has gone according to plan because various unintended consequences have routinely emerged since 2013. Among them -- and probably one of the most disturbing -- is the practice by insurance carriers engaging in discriminatory practices against people living with HIV/AIDS, as well as other so-called "expensive" chronic conditions.

Photo of the word "discrimination" in type text, with the definition of the word in the background.
Source: Human Resource Solutions

One of the earliest such practices emerged in Louisiana (and North Dakota) by Blue Cross and Blue Shield of Louisiana, which we covered in our "Tarnished Blue" blog early last year. At issue: Blue Cross and Blue Shield of Louisiana rejected third party premium subsidies from the Ryan White program on behalf of its policyholders. Left unchecked, many people living with HIV/AIDS who earn too much to qualify for Medicaid but not enough to qualify for federal subsidies for insurance plans potentially could have fallen into a coverage gap.

However, advocates were quick to respond. Lambda Legal led the charge against Blue Cross and Blue Shield of Louisiana, charging: "The situation is urgent. Refusing federal funds that provide life-saving care to people living with HIV could potentially affect thousands of low-income Louisiana residents, and if BCBS does not recognize the error of its ways and reverse course, the only logical explanation for its conduct is discrimination. This strategy keeps people living with HIV off BCBS's insurance rolls, and smacks of the sordid legacy of years of insurance industry practices designed to deny coverage to those living with HIV."[3]

After clear guidance by the federal government, and favorable legal proceedings, Blue Cross and Blue Shield of Louisiana backed down and once again started accepting third-party premium subsidies. Patients, 1; insurers, 0.

However, it didn't take long for yet another coverage crisis to emerge. "Adverse selection" has increasingly been a thorn in the side of patients. Adverse selection is the practice whereby "insurers try to encourage healthier people to buy coverage by making it difficult or even impossible for individuals with pre-existing conditions to obtain coverage."[4] In all fairness, adverse selection existed well before Obamacare, and it will probably continue to exist (in manner or another) for a long time to come.

Earlier this year,  The AIDS Institute (TAI) and the National Health Law Program (NHeLP) filed a complaint with the federal government against several health plans in Florida, accusing them of engaging in discriminatory practices against people living with HIV-infection engaging in adverse selection. That complaint has already yielded positive results for patients, evidenced by Aetna (one of the companies named in the complaint) agreeing to reduce patient costs for HIV medications nationwide in the qualified health plan marketplace. Patients, 2; insurers, 0.

That battle continues today, unfortunately. TAI announced last month that Florida would be requiring insurance plans to limit patient cost-sharing for HIV therapies starting in 2016. In other words, according to TAI, excessive co-insurance would be deemed discriminatory (TAI, 06/12/15).

Summarized Carl Schmid, Deputy Executive Director for The AIDS Institute, about the announcement by the Florida Office of Insurance Regulation: “This is a major victory for people living with HIV who rely on medications to remain healthy. We thank the Florida Office of Insurance Regulation for recognizing that insurers charging excessive co-insurance is discrimination and harms people with HIV who cannot afford the cost of their medications.”

Patients, 3; insurers, 0.

[1] CNBC, "Health uninsured rate falls, yet again, under Obamacare," July 10, 2015. Accessed on 07/14/15 at
[2] WalletHub, John S Kiernan, "Rates of Uninsured by State Before & After Obamacare," 2014. Accessed on 07/14/15 at
[3] Lambda Legal, "Lambda Legal Files Administrative Complaint Challenging Louisiana BlueCross BlueShield Policy Targeting People with HIV," February 10, 2014. Accessed on 07/14/15 at
[4] About Health, "What is Adverse Selection," June 19, 2014.

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