The most important decision before Governor Scott and the legislature is whether to expand Medicaid to an estimated 1.9 million low -income Floridians, including thousands living with HIV.
Each World AIDS Day, we review the year’s progress in the fight against the disease. Usually the focus is 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, more than 100,000 of whom live in Florida.
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 opportunistic infections.
Choices our state will make in the coming months will determine whether or not access to life-saving treatment extends to uninsured Floridians. The most important decision before Governor Scott and the legislature is whether to expand Medicaid to an estimated 1.9 million low -income Floridians, including thousands living with HIV.
Effective 2014, states can extend Medicaid to citizens 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 non-disabled 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 lifespan, 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. A recent breakthrough study 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 would stop new infections and ultimately save money.
In Massachusetts, the laboratory for health reform, Medicaid was extended to low income people living 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 in the rate decreased 25 percent. Costs for HIV positive Medicaid beneficiaries, especially inpatient care, 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.
Medicaid is a lifesaver well beyond HIV. A study published recently in the New England Journal of Medicine examined three states that expanded Medicaid before health reform. Researchers found a reduction in mortality corresponding to 2,840 deaths per year in a population of 500,000 new enrollees.
Financially, expanding Medicaid is a sweet deal for Florida, bringing in new federal dollars and offsetting costs for uncompensated care. The federal government will pay all of the costs of new enrollees for the first three years, decreasing gradually to 90 percent by 2020 and afterwards. This is still well above the 58 percent federal share for current enrollees. Analysis from the Safety Net Hospital Alliance of Florida found that the state will lose nearly $28 billion in federal funds over the next 10 years by not expanding Medicaid, while the state costs of an expansion would be about $1.7 billion. A report released just this week by the Kaiser Family Foundation and the Urban Institute found that Florida will see savings in uncompensated care of more than $1.2 billion over the next decade if Medicaid expansion happens.
Medicaid expansion in Florida will save lives and money. And it has the potential to turn around the HIV epidemic in our state. In recognition of World AIDS Day, commit yourself to contacting the Governor and your representatives about steps to diminishing the HIV epidemic in our State.
Director of Development
Rural Women’s Health Project
Senior Lecturing Fellow
Duke Law School
Treasurer, North Carolina AIDS Action Network