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Health Care in the U.S.: Closing the Gaps, Opening the Door

Fall 2008

The United States is failing when it comes to health care access. According to a report from the Commonwealth Fund (a private foundation promoting health care), the U.S. scored only 58 out of 100 points for access to care. This is a significant decline since 2006, despite the fact that we spend twice as much per person on health care as most other industrialized countries.

For people with HIV, access to health care can be a matter of life and death. Sadly, those who live in underserved areas or who lack insurance often have poor quality health care and limited services. People with HIV currently get care through several programs, including Medicaid, Medicare, Ryan White, and various state programs. This approach leaves significant gaps in coverage. Closing these gaps is a top priority for advocates. The upcoming elections for President and Congress offer important chances to focus the nation's attention on improving access to health care.

National Health Care Reform: The Obama and McCain Plans

Both presidential candidates have offered outlines of what they would do to reform our health care system. Senator Obama's plan would build on the current system of employer-sponsored health care. It would also create a new health plan similar to what is offered to federal employees. His plan would require employers to offer health insurance or to help with its cost. It would also expand Medicaid and provide money to make the new plan affordable for people with low incomes. Insurers would be required to cover everyone, regardless of health status. This is especially important for people with HIV.

Senator McCain's plan would replace the tax break for employees who get health insurance from their employers. It would provide a refundable tax credit ($2,500 for individuals, $5,000 for families) for everyone who purchases health insurance. McCain's plan focuses on individual choice, insurance competition, reforming malpractice law, and changing the way providers are paid, in order to make health care affordable. Advocates are concerned that the McCain plan offers little to those with pre-existing medical conditions.

Earlier Access to Care

A 2004 Institutes of Medicine (IOM) report found that a large percentage of HIV-positive adults do not get regular medical care, and that many were not getting care in the early stages of the disease. This is partly due to the fact that the systems for HIV/AIDS care were put in place when care was mostly given in the hospital. New medications allow many to manage HIV as a chronic illness, but the programs that pay for care have not evolved to reflect this change.

Take Medicaid, for example -- the largest payer of HIV care in the country. Current Medicaid policy requires an individual to be disabled by AIDS before becoming eligible for the care and treatment that could have prevented HIV disease from progressing to AIDS. Ironically, this puts Medicaid (a federal program) at odds with federal guidelines that recommend early treatment of HIV.

Receiving treatment early in the disease preserves health. Evidence also indicates that early treatment helps prevent the spread of HIV. A major goal for advocates is for more people with HIV to receive good care as soon as they are diagnosed. There have been several proposals for how to do this. The 2004 IOM report recommended creating a new $7 billion federal program. In the current economic climate, however, a more likely approach may be to expand Medicaid coverage to low-income people with HIV before they become disabled.

Early Treatment for HIV Act

The most promising option for expanding Medicaid coverage is the Early Treatment for HIV Act (ETHA). This bill is currently pending in Congress with support from both parties (Senate Bill 860, House Bill 3326). ETHA would give states the option to extend Medicaid coverage to low-income people who are HIV positive but who do not yet have AIDS. ETHA is a cost-effective plan that would bring Medicaid guidelines in line with the U.S. government's own standard for treating HIV. House Speaker Nancy Pelosi is a sponsor and long-term supporter of ETHA. Advocates are hopeful that ETHA will become law soon.

Protecting Medicaid Coverage

Another ongoing priority is to protect current Medicaid benefits from cuts. The Bush administration has consistently tried to reduce funding and restrict Medicaid's ability to provide HIV services. One example of a harmful proposed change is a rule that would restrict case management benefits for people with HIV. Another would restrict services covered by hospital outpatient clinics, removing care for those who can't obtain it otherwise. This would especially affect people of color, who rely heavily on outpatient clinics. Congress recently approved a freeze on the latest round of changes proposed by the Bush administration. Without ongoing education of our elected officials, however, such proposals will remain a threat.

Fixing Medicare

Many people with HIV depend on Medicare's new drug program, Part D, for their medicine. Advocates were recently successful in getting a new Medicare law passed that ensures that Part D plans will cover all HIV medications recommended by the federal HIV treatment guidelines. Under the new law, if a plan wants to exclude any of these drugs from coverage or to limit access, it must request an exception from the government after public notice and comment.

The second change sought by advocates is to include the money paid by AIDS Drug Assistance Programs (ADAPs) to Medicare clients as a part of their true out-of-pocket (TrOOP) expenses (see The Politics of ADAP). Counting ADAP as TrOOP would save ADAPs up to $44 million. This provision was not included in the recently enacted Medicare reform bill. Advocates will need to argue to the next Congress and President that it's reasonable to count ADAP payments as TrOOP.

Mending the Safety Net

As they try to mend the holes in the safety net of publicly funded health care programs, advocates should seek to expand coverage by programs such as Medicaid and Medicare. At the same time they should advocate for funding of the care and services provided by other programs, like Ryan White. Congress and the new administration need to recognize that ensuring early, comprehensive access to care and treatment for all people with HIV is a crucial step towards ending the epidemic.

The authors work together at the Health Law Clinic of Harvard Law School.

Want to read more articles in the Fall 2008 issue of Achieve? Click here.

This article was provided by ACRIA and GMHC. It is a part of the publication Achieve. Visit ACRIA's website and GMHC's website to find out more about their activities, publications and services.
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