Lack of Medicaid expansion hurts people living with HIV, advocates say

In May, Georgia Governor Brian Kemp angered residents living with HIV and their allies when he cut a line in the state budget that would have allocated more than $4 million to expand the Medicaid coverage to income-eligible HIV-positive individuals. Despite the fact that the state, whose population is booming, has the highest rate of new HIV cases in the country, Kemp technically vetoed silver. He also said he wants those funds to go into the state’s regular Medicaid program to accommodate newcomers to the state.

But it is useful to understand this disappointment in a larger context: Georgia is one of 12 states, most of them in the Southeast’s epicenter of poor health, who have still not taken up the federal government’s offer to foot almost the entire bill for extending Medicaid to people whose incomes are up to 138% above the federal poverty level. Currently, that’s about $19,000 for an individual and $38,000 for a family of four.

In the 38 states that have embraced Medicaid expansion since it was first offered in 2014 under the Affordable Care Act, tens of thousands of low-income people per state have received free full medical coverage, let alone access to Medicaid-funded health care. dots, which has improved health outcomes. On the other hand, most of the 12 states that did not expand Medicaid are among the poorest states, with the worst health outcomes in the United States, they are also almost entirely Republican-led.

Grassroots efforts to successfully expand Medicaid in these states are ongoing and have paid off in other red or purple states such as Louisiana, Virginia, and Missouri, all of which have expanded. years after his first offer. In Georgia, Democrat Stacey Abrams is making Medicaid expansion a key part of her gubernatorial campaign against incumbent Kemp in November.

Kemp’s veto of an HIV-only expansion spelled the end of what activists had seen as a piecemeal effort to tackle the state’s heavy HIV caseload.

Jeff Graham, who leads the LGBTQ advocacy group Georgia Equality and previously led the state’s AIDS Survival Project, “As we continue to advocate for the full expansion of Medicaid in Georgia through the Cover Georgia Coalition,” he and other advocates lobbied for HIV—only an expansion because “HIV care in the state through Ryan White/ADAP has reached a crisis point.” (The Ryan White CARE Act is a large federal HIV/AIDS funding program, and the AIDS Drug Assistance Program [ADAP] is the component that covers HIV drugs and sometimes non-HIV drugs and care for those who have no other insurance. ADAP will also often pay for Obamacare plan premiums and copayments for those who qualify.)

Not only are the state’s ADAP rollovers constantly increasing due to population growth, Graham said, Georgia’s ADAP currently does not cover certain HIV drugs, such as the relatively new injectable Cabenuva (cabotegravir/rilpivirine). that Medicaid would cover. “We have all these people moving to Georgia, and some find that drugs that were covered in their previous state are not covered here.”

His coalition went as far as prepare a report showing that, in Graham’s words, “if we put the same amount of state money into expanding Medicaid for HIV as we did into our ADAP, we could transition up to 12,000 people from the ADAP to Medicaid, which would free up more than $53 million in Ryan White funding.

These funds could be dedicated to the non-medical needs of people living with HIV, such as housing, transportation, mental health and addiction treatment, especially for people living in hard-to-reach rural areas. But, at least for now, that won’t happen. Because the state is putting strong funding into its ADAP, “the governor’s veto doesn’t make things worse at this time,” Graham said, “but it misses an opportunity to make things significantly better.”

Ironically, Graham noted, Kemp’s veto came alongside a long-sought victory for Georgians living with HIV. The state modernized its HIV criminalization law to require that the intention to transmit be demonstrated and to allow proof that a person’s actions did not present a risk of transmission. This could be due to the sexual act itself, the use of condoms and/or the HIV-positive person taking anti-HIV drugs and therefore unable to transmit the virus. This follows a national model recent years of such modernization laws, the result of a decade of activism.

Not a Georgia-specific issue

Georgia is not alone in not being able to provide Medicaid to more low-income people with or without HIV. If so, then these people would be able to access the full range of physical and mental health services, and likely more access points, through the program. And that, advocates say, could help reduce the stark health disparities in Southern states.

“We really don’t have a practical way to end the HIV epidemic without expanding Medicaid in southern states, where more than half of HIV diagnoses occur,” said Dafina Ward, director executive of the Southern AIDS Coalition, who advocated for increased attention. and funding the HIV epidemic in southern states since 2001. Ward lives in South Carolina, one of 12 holdout states.

“The failure to expand Medicaid in these states has a real cost to people living with HIV,” she continued. “In addition to needed coverage for HIV-related drugs, Medicaid expansion would cover other health services in states that do not have strong programs to use ADAP funds to cover premiums and copayments. shares of private health plans. The expansion could open up opportunities for increased access to health care in rural communities, address racial disparities in insurance coverage, and lead to other improved subsidies that could contribute to the holistic well-being of hundreds of thousands of people. It would provide a greater infrastructure to cover all the health care needs of people living with HIV. And it could benefit those who are HIV-negative and want access to PrEP. »

Much of what she said was echoed by Amy Killelea, an independent health policy and financing consultant who previously worked at NASTAD, which helps states manage their Ryan White programs. “States that are resisting Medicaid expansion are a completely different health care environment than others,” Killelea said. “Their decision not to expand Medicaid exacerbates other poor outcomes they have in a range of things like obesity, diabetes, and reduced access to providers.”

While in states that have expanded Medicaid, Killelea said, “The Ryan White program is able to supplement and maximize Medicaid coverage.” For example, she said, someone who previously only had ADAP, which covered HIV needs but not others, is now fully covered for all health issues, but can still access Ryan White funding for things like HIV case management.

“Ryan White wrote the book on how to provide culturally appropriate services to people living with HIV, but that should be complementary to broad health coverage like Medicaid,” she said, not in addition to it. substitute.

The shortcomings of living on ADAP but not on Medicaid are exemplified by Robin Webb, 65, a lifelong HIV survivor in Mississippi and board member of the Southern AIDS Coalition. “People here on Ryan White cannot use it to cover adjacent health conditions like diabetes,” he said in an email. “Older people like me need comprehensive coverage. Our Ryan White finally covers mental health, but only two drugs. And dental coverage is very limited.

What happens now?

Killelea referred to the federal Ending the HIV Epidemic initiative, which was started by the Trump administration but continued in the Biden administration and aims to bring new HIV cases in all states to such a low point that the epidemic essentially stops. “If we’re going to achieve these goals,” she said, “the federal government must create a fix for recalcitrant states,” such as simply offering residents of those states Medicaid directly, rather than through their states. “We can’t wait for states to do that.”

But, she said, the immediate window to do so in DC is shrinking as the midterm elections approach, which could wipe out Democrats’ already wafer-thin majorities in the House and Senate. Efforts to do so since Biden took office have stalled.

Kathie Hiers, veteran CEO of AIDS Alabama, said she’s part of a longtime coalition in her state to expand Medicaid. They will have another chance, she said, after the gubernatorial election in November in which Republican incumbent Kay Ivey, who just won her primary, will almost certainly win in the reliable red state.

“There have been a lot of rural hospital closures, which is a direct result of the lack of Medicaid expansion,” Hiers said. (More Medicaid patients means more federal reimbursements, which means more money for health centers to open or stay afloat.)

“I know Kay Ivey doesn’t want [the closing of all our hospitals] be his legacy,” Hiers said.

She also echoed Graham saying that what doesn’t seem like an acute emergency today could become one tomorrow. “It’s true that most of the needs of people living with HIV in Alabama are covered by Ryan White because we buy insurance for them, but I don’t know if that’s sustainable. It’s discretionary funding that we have to fight for every year, and an administration less friendly than Biden could diminish it or eliminate it.

She pointed to Louisiana, which in 2016 became one of the few Southeast states to expand Medicaid. “Transferring people living with HIV from Ryan White to Medicaid was a bit difficult at first, but they got through it. And now people living with HIV have a health care program that cannot be taken away from them.

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