When we review the nation’s progress in the fight against HIV/AIDS, the focus is usually on medical advances. But this year, the innovation that could turn the tide of HIV in the United States is not a drug – it’s the prospect of access to health care for the 1.2 million Americans living with HIV, some 35,000 in North Carolina alone.
The Affordable Care Act is now on track to extend coverage to millions of uninsured Americans, including many with HIV/AIDS. Nationally, about 29 percent of people living with HIV are uninsured. Without insurance, they are less likely to control their virus, more likely to transmit HIV to others and more likely die of AIDS.
Whether access to life-saving treatment extends to uninsured North Carolinians hinges on choices our state will make in the coming months. The most important decision before Gov.-elect Pat McCrory and the legislature is whether to expand Medicaid to an estimated half million low-income North Carolinians, including thousands living with HIV.
Effective 2014, states can extend Medicaid to residents making less than 138 percent of the federal poverty level ($15,415 in 2012). Currently, eligibility for Medicaid is limited to very low-income parents, children, elderly and the disabled. There is no coverage for nondisabled childless adults under 65, no matter how poor.
This limited access to Medicaid is particularly cruel for people with HIV. New drugs promise a nearly normal life span but are prohibitively expensive for most. To qualify for Medicaid, people must become sick enough to meet strict federal disability requirements and be unable to work. Those who can’t meet the disability requirements must cobble together help from the AIDS Drug Assistance Program, the federal Ryan White program, hospital charity and pharmaceutical assistance programs, none of which provide the seamless, comprehensive care needed to keep the virus in check.
In spite of the herculean efforts of AIDS services organizations, doctors, social workers and public health officials, many still fall through the cracks.
This is not just a personal tragedy – it also poses a public health risk for the entire community. Researchers at UNC, in a breakthrough study that has garnered worldwide attention, showed that controlling HIV with antiretroviral drugs reduces transmission by 96 percent. When we fail to provide access to care, we generate new, expensive HIV cases. Expanding Medicaid would not only improve outcomes for those already infected, it also would stop new infections and ultimately save money.
Massachusetts, the laboratory for health reform, extended Medicaid to low-income people with HIV/AIDS in 2001. Since then Massachusetts has outpaced every state in controlling the spread of HIV and its costs.
While nationally the rate of new HIV infections increased 2 percent from 2006 to 2009, in Massachusetts the rate decreased 25 percent. Costs for HIV-positive Medicaid beneficiaries have declined. The Massachusetts Department of Public Health estimates that reforms reduced HIV health expenditures by about $1.5 billion over the past 10 years.
Financially, expanding Medicaid is a sweet deal for North Carolina, bringing in new federal dollars and offsetting costs for uncompensated care. The federal government will pay the full cost of new enrollees for the first three years, decreasing gradually to 90 percent by 2020. This is still well above the 64 percent federal share for current enrollees.
Although some new enrollees will have medical conditions like HIV, most are projected to be healthier and thus cheaper to insure than those currently on Medicaid. The state has estimated that over the first six years, expanding Medicaid will cost $830 million, but it will bring in over $15 billion in new federal dollars. The Urban Institute projects that over this same period North Carolina will see savings in uncompensated care of $1 billion to $2 billion.
Medicaid expansion in North Carolina will save lives and money. And it has the potential to turn around the HIV epidemic in our state. Let’s hope McCrory and our legislature act quickly in the new year to expand Medicaid, for those with HIV, those at risk and everyone struggling to afford care.
Allison Rice is senior lecturing fellow at Duke Law School and treasurer of the North Carolina AIDS Action Network.