What does the Affordable Care Act (ACA) mean for 1.2 million Americans living with HIV or AIDS, as well as for efforts to halt the epidemic in the U.S.? As the new reforms go into effect, and health care delivery and payment models change, there are many questions about how people affected by HIV, especially those with low incomes, will be able to access prevention and treatment services.
Given the disproportionate impact of HIV on gay and bisexual men, other MSM (men who have sex with men), and transgender people, the answers will be greatly influenced by how well the ACA helps LGBT people secure the care they need.
Now, a study by the Center for American Progress (CAP) shows striking progress in this direction. And from Jan. 12 to 18, the nationwide Out2Enroll initiative and its partners in National LGBT Outreach and Enrollment Week aim to help even more LGBT people access coverage.
To assess the difference that the ACA may be making in combatting uninsurance among LGBT people, CAP conducted a nationally representative study that looks at the health coverage and care experiences of LGBT people with incomes under 400% of the Federal Poverty Level -- those potentially eligible for financial assistance under the health reform law to help them access affordable coverage.
The findings are promising: In 2013, one in three LGBT people (34%) in this income range were uninsured. By 2014, after the first full open enrollment period under the ACA, the prevalence of uninsurance among low- and middle-income LGBT individuals had dropped significantly, to one in four (26%).
Among gay men, uninsurance dropped from 34% to 27%; among lesbians, from 31% to 21%; among bisexual people, from 29% to 27%; and among transgender people, from a shocking 59% in 2013 to 35% in 2014.
LGBT people with incomes between 139% and 200% of the Federal Poverty Level made particularly significant gains: Between 2013 and 2014, uninsurance in this income range dropped by 22 percentage points, from 48% to 26%.
Of all respondents who explored their coverage options during the first open enrollment period,
- 35% found out they were eligible for Medicaid coverage -- of whom 78% enrolled.
- Among those who were not Medicaid-eligible, 20% purchased a plan through a Health Insurance Marketplace.
- Almost half of those who purchased coverage were able to select a plan that costs less than $100 per month.
But much work remains to be done to ensure that the ACA effectively addresses uninsurance in LGBT communities. We found that 26% of LGBT people who could potentially get financial help to get covered were uninsured in 2014 -- compared to an estimated 20% among the general population in the same income range.
Reasons given for uninsurance included employment discrimination, which traps many LGBT people in poverty and lower-wage jobs that don't offer benefits, and insurance exclusions targeting transgender individuals and others considered to have pre-existing conditions. Respondents in same-sex relationships also reported persistent barriers to coverage: In both 2013 and 2014, approximately 50% of those who had tried to access coverage for a same-sex spouse or partner reported encountering trouble, and nearly three in four reported feeling discriminated against in the process.
Though the study did not ask participants about their HIV status, almost 5% of respondents who needed care related to HIV or AIDS, including preventive care, reported trouble getting coverage. African-American respondents who needed HIV-related care were significantly more likely than white respondents to report having trouble (13% versus 1%). Respondents with incomes between 201% and 300% of the Federal Poverty Level -- the income range where many lose access to means-tested programs such as the Ryan White AIDS Program and its AIDS Drug Assistance Program (ADAP) and must take their chances with private coverage -- were significantly more likely than those with lower incomes to report difficulties (17% versus 3%).
These findings are particularly disturbing in light of recent reports that some insurance carriers participating in the Health Insurance Marketplaces are engaging in discriminatory practices such as imposing expensive cost-sharing arrangements for HIV medications.
But despite these and other challenges in the law's implementation, this study suggests that the ACA is making a real difference in helping LGBT people connect with their new coverage options. And with coverage has come care: 72% of respondents who got new coverage in the first open enrollment period used it to access health care, of whom 94% reported positive experiences with getting the care they needed.
A key step in continuing to make health reform a success for LGBT people, including those living with HIV, is community education. Even five years after the law's passage, a widespread lack of accurate information continues to sow confusion and skepticism in LGBT communities.
As a member of a gay focus group in Atlanta shared, "I really didn't bother to look into [the ACA] because what it was supposed to be for was clouded with political buffoonery, so I really couldn't hear what it was really meant for. ... It wasn't until I was diagnosed with HIV later on that year where I had to understand how this can possibly affect me."
To help LGBT community members better understand their new coverage options and to enroll in coverage, the week between Jan. 12 and 18 has been designated National LGBT Outreach and Enrollment Week. To get free help assessing coverage options, LGBT people can visit the Out2Enroll campaign's web locator tool to search by zip code for LGBT-friendly enrollment assistance in their local area. All of us can further the impact of the ACA in HIV prevention and treatment by using these tools to ensure more people can enroll in coverage and get the care they deserve.
Kellan Baker, M.P.H., M.A., is a senior fellow with the LGBT Research and Communications Project at the Center for American Progress, where he works on a range of LGBT health policy issues. Baker is a founding steering committee member of Out2Enroll, a nationwide initiative that works to connect LGBT people and their families with new health insurance coverage options under the Affordable Care Act.