The Affordable Care Act represents a historical step toward improving the health of the American people, as important as the creation of Medicaid and Medicare 47 years ago. We commend the U.S. Supreme Court for upholding the right of our elected representatives -- our Congress and president -- to address these critical issues. Today's court decision upholds important protections against discrimination in health-care delivery and helps ensure access to lifesaving care and services for millions of Americans, including lesbian, gay, bisexual, and transgender (LGBT) people and people living with HIV/AIDS.
The Affordable Care Act provides LGBT people in the roughly 40 states that don't recognize same-sex relationships with more affordable insurance options. Most of these states also ban domestic-partner recognition, including health insurance for same-sex partners of municipal or state government workers. Because of the slew of anti-gay family laws and amendments that stripped thousands of same-sex partners of their employer-provided health insurance, as well as discrimination against gay families by private insurance companies, LGBT people are much less likely to have insurance coverage. Lesbians and transgender people are much less likely than others to access preventive health care. For all these reasons, the ACA's expansion of health-care access is critically important to LGBT Americans.
The ACA also provides support for preventative care and HIV testing, treatment, and prevention services. It prohibits insurance companies from canceling coverage for preexisting medical conditions, including for people living with HIV. Today only 13 percent of the estimated 1.2 million Americans living with HIV in the U.S. have private insurance, and 25 percent have no insurance. Only half of people with HIV in the U.S. are in regular medical care, and less than a third are being treated effectively such that they are virally suppressed. The preexisting condition provision will mean that thousands of people living with HIV will soon have health coverage, which will improve treatment outcomes, a key goal of President Obama's National HIV/AIDS Strategy.
The Affordable Care Act also provides resources to expand community-based care to help meet our country's growing health-care needs and to provide more access to primary care providers in the hopes of keeping people healthier and cutting down on expensive emergency-room visits and hospitalizations. Much funding is going to community health centers. The Fenway Institute's National LGBT Health Education Center is working to ensure that community health centers are able to provide clinically competent care to low-income LGBT people seeking health care and thereby reduce disparities.
The Supreme Court appears to have upheld the federal government's ability to promote expanded Medicaid coverage in the states through expanded federal funding (a carrot), but not the ACA's provision that would cut all federal Medicaid funding to states that don't comply (a stick). About half of the 30 million people newly able to access health coverage under the ACA would be covered under the Medicaid expansion, including low-income adults who are not disabled and who don't have dependent children. This expansion would benefit many individual LGBT people, as well as millions of other low-income Americans.
We are particularly concerned that many states that may reject Medicaid expansion, and even federal funding to support it, for ideological reasons are also home to some of the most striking health disparities, particular for racial/ethnic minorities and poor people. This means that the critical work of promoting expanded health-care access to millions of low-income Americans will necessarily shift to the state level.
States should support the Medicaid expansion, as it is a good deal for them. As Robert Greenwald of Harvard Law School points out, under the ACA, the federal government first contributes 100 percent of the cost of the expansion, then 95 percent, and then 90 percent. Second, the private-insurance-premium subsidy only covers people with incomes at or over 100 percent of the federal poverty level (FPL) up to 400 percent of the FPL. If a state declines to pick up the expansion option, the poorest people in the state (who don't meet existing Medicaid eligibility criteria) will not have any coverage. States should not leave people whose incomes are below the poverty level more vulnerable than those who qualify for premium subsidies.
If the ACA is to be successfully implemented, supporters must ensure that a meaningful expansion of Medicaid occurs in states across the country. We must also ensure that insurance offered in state health-insurance exchanges meets the health-care needs of people with HIV and LGBT people, does not reinforce existing discriminatory practices, and allows us to reduce health disparities affecting LGBT people.
Sean Cahill is Director of Health Policy Research at the Fenway Institute and Adjunct Assistant Professor of Public Administration at New York University.
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