In his State of the Union address in February 2019, Donald Trump vowed to end the HIV epidemic by 2030.
But if Trump has his way and the supreme court strikes down the Affordable Care Act (ACA), the resulting seismic disruption to the healthcare system would end that dream.
Democrats have expressed grave concern that if Amy Coney Barrett is seated on the supreme court, the conservative jurist could cast a decisive vote to destroy the ACA in the California v Texas case scheduled for oral argument starting 10 November. The Senate judiciary committee committee voted to advance Barrett’s nomination on Thursday. A full Senate vote is expected on Monday.
The brainchild of Dr Anthony Fauci and other top brass at the Department of Health and Human Services, the ambitious Ending the HIV Epidemic: A Plan for America has received for its debut year $267m in new federal spending, largely targeted at HIV transmission hotspots across the US.
The central aim of the Trump-backed plan is to improve access to antiretrovirals, given that successfully treating HIV with such medications eliminates transmission risk. For HIV-negative people, the plan promotes greater use of PrEP – a daily antiretroviral tablet that cuts the risk of HIV by more than 99% among gay and bisexual men, who are its predominant users and account for seven in 10 new infections.
Given antiretrovirals’ enormous cost, the ACA and its broadening of insurance access serves as backbone to the HIV plan, which seeks a 90% reduction by 2030 to the otherwise slowly declining or stagnant national HIV transmission rate of about 37,000 new cases annually.
“The plan is dead in the water if the ACA goes down,” said Amy Killelea, senior director of health systems and policy at Nastad, an HIV public policy non-profit.
“President Trump’s healthcare agenda, in particular his plan to get the supreme court to rule against families’ healthcare, does more to end access to HIV care than it does to end HIV,” said the Washington state senator Patty Murray.
‘Heartbreaking and morally indefensible’
Kaiser found that between 2012 and 2018, the proportion of the non-elderly HIV population lacking insurance declined from about 18% to 11%. This shift was mainly driven by the expansion of Medicaid in the states that opted under the ACA to open the program to all residents with incomes below 138% of the federal poverty level.
“Striking down the ACA would lead many people with HIV to lose insurance coverage,” said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation.
Medicaid expansion has also been tied to increased HIV testing and PrEP use. In Louisiana, the only state in the deep south to expand Medicaid, state officials attributed a 12% decline in HIV diagnoses between 2015 and 2018 to such effects.
For an overall population as vulnerable and stigmatized as those living with and at risk for HIV – one that is disproportionately Black and Latino, with a high rate of substance use disorders, mental illness, homelessness, incarceration and especially during the Covid-19 pandemic, unemployment – a sudden loss of health insurance can prove critically disruptive to consistent healthcare engagement and access to antiretrovirals.
When individuals stop taking such medications, HIV can spread more widely as viral load rises to a transmissible level in people with the virus and HIV-negative people lose PrEP’s protection.
The pandemic has already disrupted such access. Preliminary analyses point to rising rates of unsuppressed HIV and major declines in PrEP refills and testing for the virus in recent months.
“In light of the extraordinary public health and economic challenges we are currently facing, the idea that the supreme court would reverse the great progress we have made in efforts to eliminate HIV in the United States is heartbreaking and morally reprehensible,” said Robert Greenwald, director of the Center for Health Law and Policy Innovation at Harvard Law School.
The federal Ryan White HIV/Aids Program and its $2.4bn budget will continue to provide uninsured people with HIV with at least some form of safety net, helping to cover care and treatment should Obamacare fall.
But since the ACA’s major insurance provisions launched in 2014, Ryan White has undergone a major shift, especially in Medicaid expansion states, toward focusing on covering ancillary “wraparound” services for insured people with HIV, such as case management, housing and transportation. The program also increasingly pays for private Obamacare plan premiums. These shifts, research indicates, have improved viral suppression rates.
Ryan White’s wraparound coverage would dissipate if funds were more urgently needed to address an insurance-loss surge. Kates and other experts predict the program might not prove nimble enough to promise a smooth transition into a post-ACA era.
Experts also fear a return of waiting lists for HIV treatment coverage by the Aids Drug Assistance Program, a Ryan White component that co-funds medication or health insurance premium coverage with the states. These notorious lists have tended to lengthen during economic downturns, thanks to tightening state budgets.
Decimating the ACA would also vaporize numerous less widely appreciated facets of the law that provide crucial protections for insured people living with and at risk for HIV. These include the elimination of annual and lifetime coverage caps, the establishment of annual caps on out-of-pocket costs, and the promise of no such costs for validated preventive services, such as HIV testing and PrEP. The law’s anti-discrimination provisions have also helped ensure more equitable healthcare access.
Trump’s claim he can simply forbid pre-existing condition exclusions by executive order notwithstanding, a loss of this cherished ACA-guaranteed protection would, Kaiser research indicates, render people with HIV uninsurable on the open market.
The opioid crisis, which along with other forms of substance abuse has begun to reverse the two-decade decline in HIV diagnoses among people who inject drugs, is also poised to worsen if the nation loses ACA-based coverage for mental health and substance use disorder treatment in particular.
Greg Millett, director of public policy at amfAR, The Foundation for Aids Research, noted that during a year defined by urgent calls for racial justice, the harsh demographic realities of the intersecting Covid-19 and HIV epidemics serve as prime examples of the nation’s long failure to address race-based health inequities.
“It’s no mistake with this administration that they are not following the science comprehensively in addressing HIV, nor Covid-19,” Millett said. “And unfortunately, not following the science to address HIV or Covid-19 primarily impacts people of color.”
The Trump administration’s “ham-fisted” handling of Covid-19, Millett said, has already jeopardized achieving the goal of ending the HIV epidemic by 2030.
Michelle Collins-Ogle, a pediatric and adolescent HIV physician at Montefiore medical center in the Bronx, expressed outrage over conservatives’ dogged battle to destroy the signature legislative achievement of the Obama administration, the ACA.
“Here I am, working hard to take care of people who are indigent and vulnerable,” Collins-Ogle said. “And you want to take away from me the one tool I have to make sure that I do the best for these people?
“How dare you?”