On March 23, President Barack Obama signed the sweeping $940 billion Patient Protection and Affordable Care Act, ending his and other Democrats’ yearlong struggle with Republican opponents in Congress (and vocal throngs of Tea Party protesters) to extend health coverage to 32 million uninsured Americans and require most citizens to purchase insurance. Obama lent his pen to a separate reconciliation bill—which includes a package of “fixes” to the Senate version of the bill—one week later.

HIV/AIDS organizations from around the country are applauding the measure, which includes several provisions that will improve the lives of people living with the virus.

“The president and Congressional leaders are to be commended for championing legislation that will extend health insurance coverage to nearly 95 percent of all people in the U.S. when the program is fully implemented,” David Ernesto Munar, vice president of the AIDS Foundation of Chicago, told POZ. “For the fight against HIV/AIDS, nothing could be more important. Health inequality perpetuates late testing and entry into care, HIV-related health disparities and high rates of preventable infections and deaths. Medicaid expansion, Medicare fixes and greater insurance market regulation will make vital health and preventative care services more affordable and accessible for people living with and at risk for HIV/AIDS.”

For HIV-positive Americans, perhaps the most important piece of the new legislation is its provision barring insurance companies from denying or discontinuing coverage based on preexisting conditions, which include HIV/AIDS and other chronic illnesses such as cancer, diabetes or heart disease. The provision goes into effect in 2014 for adults, but will apply to children and teens starting in September.

“With HIV, both because of its medical component but also around the stigma associated with it, there are many people who dread their employer, particularly a new employer, finding out about their status,” says Marjorie J. Hill, PhD, chief executive officer of Gay Men’s Health Crisis, a leading New York City AIDS service organization. “And while this bill doesn’t necessarily change the stigma piece—we still have lots of work to do—it does mean that if someone who is HIV positive changes their job, they don’t have to worry about losing their medical benefits.”

Furthermore, the law prohibits caps on how much health care a plan will cover during a person’s lifetime. It also adds 16 million people to Medicaid—the federal health program for low-income people and those with certain disabilities—by raising the eligibility threshold to 133 percent of the poverty level. At present the federal poverty level stands at $14,404 for individuals and $29,326 for a family of four.

Many advocates, such as Kathie Hiers, CEO of AIDS Alabama and member of the Presidential Advisory Council on HIV/AIDS, hope the bill takes some pressure off individual states’ AIDS drug assistance programs (ADAP). According to a recent report by the National Alliance of State and Territorial AIDS Directors (NASTAD), ADAPs in 11 states have been forced to put a total of 777 people on drug waiting lists this year as of March 25.

“A lot of people living with HIV are now going to qualify for Medicaid, so we’re very excited about that,” Hiers says. But she advises people living with HIV that the Medicaid expansion— including the aforementioned preexisting conditions provision and the ability to buy coverage through state-run marketplaces called “exchanges”—does not go into effect until 2014.

“We’ve got a ways to go before all of this gets implemented,” Hiers explains. “I would encourage [HIV-positive] folks to be careful to protect the benefits they have now and not do anything to lose their placement on an ADAP or anything like that, until these changes actually do go into effect and we see how states are going to be able to afford them.”

Of particular interest to people living with HIV—especially those of advancing years or classified as “disabled” because of an AIDS diagnosis—is the law’s provision that would close the Medicare treatment gap, colloquially called the “doughnut hole,” by 2020, making prescription medications more affordable for senior citizens and people with AIDS. In addition, the bill prevents Medicare recipients who receive their HIV treatment through an ADAP from being subject to additional prescription drug costs.

In spite of these successes, many advocates say they are disappointed that the Early Treatment for HIV Act (ETHA) did not make it into the final version of the bill. ETHA would give states the option of extending Medicaid coverage to low-income people who are HIV positive but have not yet progressed to AIDS, at which point they would be considered disabled. However, others argue that since the new law extends Medicaid to all Americans with incomes within 133 percent of the federal poverty level, many HIV-positive people will be eligible for coverage. ETHA advocates were hoping to extend Medicaid for HIV-positive people within 200 percent of the poverty level.

“There were some legislators who suggested that maybe there wasn’t going to be a need [for ETHA] because of health care reform,” Hill says. “But we felt there was a strong need and there obviously continues to be a need. Medication is still a challenge for many individuals.”

Many advocates also lament the relatively early abandonment of the measure’s “public option,” which would have been a government insurance option to compete with private companies.

“I think we could have done better with health care reform,” says Jay Adams, president of the AIDS Task Force of the Upper Ohio Valley and HIV care coordinator for the Ryan White Part B program in West Virginia. “But given the political environment, I think we did the best we could.”

In spite of some health care reform setbacks, Hill reminds the HIV advocacy community to remain vigilant in supporting—and advising—the president on issues most important to those living with the virus. 

“The Obama administration is a friend, and with so much hope and so much need, it’s easy to forget that,” Hill says. “We need to stand with our friend—but not stand silently.”

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