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Keeping the End in Sight: Beyond Open Enrollment

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Millions of uninsured and underinsured Americans will have access to new health coverage options as open enrollment commences next week. This includes countless individuals whose HIV infection previously rendered them ineligible for health insurance, many of whom currently rely on AIDS Drug Assistance Programs and the "payer of last resort" Ryan White program to cover their medical care and daily HIV medications.

There is no doubt that new health coverage plans and programs under the Affordable Care Act can improve the lives of millions, and San Francisco AIDS Foundation and other organizations across the country are working to smooth the transition for people living with HIV. The foundation's legislative advocacy team has been fully engaged and collaborating with other agencies to help clients and providers prepare, navigate the system, and get the most out of the changes ahead.

But let's be clear: This stage of ACA implementation is just a step in the process toward the broader goals of improving health care access, engagement in care, and health outcomes for all.

While we use the term "health care reform" as a convenient catch-all to describe ACA implementation, what's initially changing, starting Oct. 1, isn't health care but who pays for health care. Will it get people closer to accessing diagnostic tests, preventive care, and medical treatment? Certainly. Will it end the HIV crisis in marginalized communities across the country? No, not on its own.

Today, of the estimated 1.1 million people in the U.S. who have HIV, only two thirds are aware of their infection and linked to HIV care. Half actually remain in care and are receiving HIV treatment, and just 25 percent have suppressed their viral load. That last statistic bears repeating: Only a quarter of Americans living with HIV have the medical care, treatment regimen, and medication adherence support they need to keep the virus in check; the other 75 percent are at risk for disease progression and for passing HIV on to others.

And in regions across the U.S., the most marginalized and stigmatized communities continue to be hit hardest by HIV/AIDS. They include men who have sex with men, transgender women, people of color, individuals who inject drugs, people who lack stable housing, sex workers, people facing language barriers and/or uncertain immigration status, and those living in poverty.

It's because of these dire statistics and health inequities that San Francisco AIDS Foundation and other HIV/AIDS service organizations provide the services we do: HIV testing in safe, nonjudgmental settings; syringe exchange programs that offer medical care referrals (and compassion), not just clean needles; substance use and mental health treatment services that welcome all; housing support, so that folks have a place to store their meds and cook a meal to go with their pills; benefits counseling to help navigate complex medical and benefits systems (and now the transition to new payers under the ACA).

Access to new health care coverage options will be life-changing for countless people who have never before been able to afford decent medical treatment. Yet this facet of the ACA does not solve many of the problems that San Francisco AIDS Foundation and other organizations have been addressing for decades. For the most marginalized among us, stigma and discrimination bar the way to HIV testing, treatment, and care.

Ensuring access to culturally competent, high-quality health care for vulnerable populations is one of the ACA's long-term goals -- and one that San Francisco AIDS Foundation shares. Culturally competent care is not a luxury. It can mean the difference between life and death: Recent research links good patient-provider relationships and communication with fewer missed appointments (a key factor in mortality risk). It is crucial that community-based organizations be part of longer-term ACA implementation planning, to ensure that the definition of "culturally competent" meets the needs of all people living with and at risk for HIV.

We welcome the positive changes ahead, and we will prepare and assist our clients and the community we serve to navigate the complex transition to new health care plans and payers. The process will advance, we will be a part of it, and our work to bring about the end of HIV/AIDS once and for all will advance as well.