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HIV/AIDS Advocates Cautiously Applaud Supreme Court Upholding Affordable Care Act

On June 28, 2012, the U.S. Supreme Court by a 5-4 margin upheld the individual mandate provision of the Patient Protection and Affordable Care Act (ACA), but declined to require states to expand their Medicaid programs. Advocates generally praised the ruling -- noting that people with HIV will benefit from the ACA's ban on insurance exclusion due to pre-existing conditions -- but said the law could actually make it more difficult for some low-income individuals to obtain care.

In a surprise outcome, Chief Justice John Roberts agreed with the 4 more liberal justices (Stephen Breyer, Ruth Bader Ginsburg, Elena Kagan, and Sonia Sotomayor) that the individual mandate is constitutional. However, he based his decision not on the Interstate Commerce Clause, as most expected, but rather on Congress' power to levy taxes. That is, he did not agree that the federal government can compel people to purchase insurance from private companies, but did say that the government may impose a tax penalty if they fail to do so, noting that "taxes that seek to influence conduct are nothing new."

One way the ACA aimed to expand coverage was by enabling an estimated 17 million more people -- those with incomes up to 133% of the poverty level -- to enroll in Medicaid, which is jointly funded by federal and state governments. But yesterday's ruling held that the federal government may not coerce states to broaden their programs by withholding existing Medicaid funding.

Conservative states that are likely to resist expanding their programs have some of the highest poverty rates, and it is now unclear how low-income individuals will be covered. Several governors and legislators have already said that their states cannot afford additional to spend more on Medicaid.

The ACA already mandates coverage of certain preventive services and allows young people to remain on their parents' insurance plans until age 26. The full law -- including state-based insurance exchanges, removal of pre-existing condition rules, and subsidies for people who cannot afford insurance -- is scheduled to go into effect in January 2014. The upcoming election could derail this timeline, however, as Republican legislators and likely presidential nominee Mitt Romney have vowed to repeal the ACA.

The full Supreme Court ACA opinion is available online at http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf.

HIV/AIDS Advocates Respond

Reaction to the Court's ruling from HIV/AIDS and other health advocates was generally favorable, though many expressed concern about the law's shortcomings.

"Expanding affordable, meaningful health care coverage is critical to people living with HIV, many of whom are poor, and all of whom by definition have a pre-existing condition," said National Association of People with AIDS (NAPWA) president and CEO Frank Oldham, Jr. "When poor people with HIV cannot access regular health care, they don't just get sick, they die -- and their deaths are expensive. Today's ruling brings us one step closer to ensuring that all PLWHA receive the medical treatment and care they urgently need."

Expanding coverage is important to all Americans, not only those living with HIV, because excluding poor people and those with pre-existing conditions burdens the health care system with expensive, late-stage illnesses that could have been prevented by routine care, NAPWA explained.

"This is a major victory for people with HIV/AIDS and hepatitis C, who need an assured source of affordable, quality health care and treatment in order to live healthy and productive lives and reduce new infections," according to a statement by Project Inform. "It is of particular importance to uninsured people living with hepatitis C who currently do not have a safety net like the Ryan White Program. The Supreme Court decision allows the ACA to clear a major hurdle and advocates can now focus on successful implementation and removing any barriers that would cause health disparities."

"The Supreme Court ruling today upholding the Affordable Care Act as the law of the land is a significant victory for people with HIV infection and the public health of our nation," said HIV Medicine Association (HIVMA) president Judith Aberg. "The ACA corrects the injustices of our current health system, which often denies health insurance coverage to those who need it the most."

According to HIVMA, fewer than 15% of people with HIV have private insurance coverage and at least one-quarter are uninsured.

"The ACA creates a level playing field for them and others with serious and chronic conditions by expanding Medicaid to all low-income individuals and creating regulated state-based exchanges for purchasing insurance," Aberg continued. "These provisions are made possible by the individual mandate and the other policies upheld today that are vital to offering the more than 50% of people with HIV not in care the opportunity to benefit from lifesaving HIV care and treatment."

Ryan White Medical Providers Coalition co-chairs Jim Raper and Barbara Gripshover emphasized that in moving forward with implementation of the ACA, Congress and the Obama administration should ensure adequate support for HIV medical services currently supported by the Ryan White Program. "These critical services both improve lives and save money," they said. "There are an estimated 1.2 million individuals living with HIV in the United States and they all need access to high-quality, continuous care to stay healthy, reduce new HIV infections, and cut long-term health care costs."

"This is a victory for all Americans, but in particular, the Court's decision today will save the lives of many people living with HIV -- as long as states do the right thing," stated Lambda Legal, which joined several other LGBT and HIV/AIDS advocacy groups in a friend-of-the-court brief supporting the Obama administration's defense of the ACA.

"The Affordable Care Act will finally allow people living with HIV to access medical advancements made years ago but that have so far remained out of reach of many," Lambda Legal's statement added. "With continuing prevention education, early detection, and quality care for everyone living with HIV, we have the power to stem the HIV/AIDS epidemic."

"The Affordable Care Act represents an historical step toward improving the health of the American people, as important as the creation of Medicaid and Medicare 47 years ago," said Stephen Boswell, president and CEO of Fenway Health in Boston. "The Court’s decision upholds important protections against discrimination in healthcare delivery and helps ensure access to life-saving care and services for many Americans, including LGBT people and people living with HIV/AIDS."

"By upholding the centerpiece of the Affordable Care Act, the Supreme Court has ensured that millions of uninsured people will finally gain access to affordable care and enable the federal government to begin addressing the shameful disparities that lesbian, gay, bisexual, and transgender people face in gaining access to healthcare," said National Center for Lesbian Rights (NCLR)executive director Kate Kendell. "At the same time, the Court's ruling puts the healthcare of low-income people at risk. Much work remains to be done to ensure that all Americans have access to quality care."

The ACA includes numerous provisions designed to prevent discrimination
in healthcare settings, according to the NCLR. State insurance exchanges are required to prohibit discrimination on the basis of sexual orientation and gender identity. The law extends federal nondiscrimination protections to the healthcare system, including protecting people from discrimination based on disability status (including HIV/AIDS) and sex, which has often been interpreted to include gender identity and gender nonconformity.

Some advocates, however, emphasized the people that the law leaves out.

"The fight over healthcare is not over," said long-time activist Nelson Vergel, founder of the Program for Wellness Restoration. "Today's decision means that state lawmakers will have to pass legislation to establish insurance exchanges that will allow uninsured people and small businesses to access quality healthcare coverage at affordable prices...Additionally, the state legislatures will be forced to make a decision on how to provide healthcare for their uninsured people. If a state turns down the billions of federal dollars it is set to receive through a Medicaid expansion, local hospital districts funded through local property taxes will continue to bear the burden of funding care for indigent people."

NAPWA emphasized that ACA's Medicaid expansion provisions are critical to ensuring coverage for thousands of people with HIV currently without insurance.

"We are concerned that the states likeliest to refuse to implement expansion are states with rapidly growing epidemics in under-insured and under-served populations of color...NAPWA calls upon all states to take full advantage of the Medicaid expansion provisions made available to them in the Affordable Care Act. The fiscal incentives provided by the federal government are generous to a point where it would be unconscionable and inexcusable for a state to fail to provide its low-income residents with health coverage."

"With the narrowing of the Medicaid expansion provisions, the very real possibility exists that many low-income individuals will not have access to affordable health care coverage," added Stephanie Arnold Pang of the National Coalition of STD Directors. "Patients at STD clinics are young, minority, and poor -- populations that bear a much higher burden of [sexually transmitted diseases] -- and may be left without coverage in a state that may choose not to expand their Medicaid coverage."

Undocumented immigrants, in particular, are left out of the ACA, which covers U.S. citizens and legal residents who have lived in the country for 5 or more years. Individuals in states such as California that currently provide some medical care to undocumented people could actually end up worse off under the new law.

6/29/12

Sources

J Rau and J Appleby. Justices Uphold Individual Mandate, Set Limits On Medicaid Expansion.Kaiser Health News. June 28, 2012.

A Liptack. Supreme Court Lets Health Law Largely Stand, in Victory for Obama. New York Times. June 28, 2012.

J Aberg, HIV Medicine Association. Supreme Court Decision on Affordable Care Act Offers Great Promise in Fight against AIDS. Press release. June 28, 2012.

S Arnold Pang, National Coalition of STD Directors. Impact of ACA Ruling on STD Prevention. Media advisory. June 28, 2012.

S Boswell, Fenway Health. Fenway Health Commends Supreme Court On Affordable Care Act Decision. Press release. June 28, 2012.

Lambda Legal. U.S. Supreme Court Upholds Affordable Care Act: Lambda Legal Will Press for Expanded Coverage. Press release. June 28, 2012.

NAPWA Applauds Supreme Court Decision Upholding the Affordable Care Act. Press release. June 28, 2012.

National Center for Lesbian Rights. NCLR Responds to Supreme Court Decision Upholding the Affordable Care Act. Press release. June 28, 2012.

Project Inform. The Supreme Court Largely Upholds the Affordable Care Act. Press release. June 28, 2012.

J Raper and B Gripshover. Ryan White Medical Providers Coalition Co-Chairs Statement on the Supreme Court’s Affordable Care Act Decision. Press release. June 28, 2012.

N Vergel. Today's Supreme Court Decision on Health Care Reform - The Fight is Not Over and it is Now up to the States. PoWeR blog. June 28, 2012.