As the nation turns its eyes toward the Supreme Court and its review of the Patient Protection and Affordable Care Act (the "ACA") this coming week, people living with HIV and their advocates will be among those watching carefully and most anxiously awaiting the outcome. For many of the approximately 1.2 million people with HIV in this country, the Court's decisions will directly affect access to quality care and life-saving treatment. Though not by any means the only group with a great deal at stake here, those affected by HIV present an exceptionally strong example of the positive impact the ACA will have, and a particularly compelling argument for the statute's constitutionality.
People living with HIV have been systematically excluded from the health-care insurance and health-care markets. Only 17 percent of people living with HIV have private health insurance, compared with 67 percent of the general population. While some of the remaining 83 percent have insurance through public programs (e.g., Medicare, Medicaid, the VA, etc.), nearly 30 percent are forced to rely exclusively upon the often spotty benefits provided through the overburdened and underfunded Ryan White programs, or to go without care altogether.
The consequences of this patchwork quilt of health care for people living with HIV are devastating: they discover their status later, go longer without lifesaving care and treatment, suffer greater complications and poorer health outcomes, and continue to die at frustratingly high and unnecessary rates. These negative consequences are more pronounced and concentrated in already marginalized populations, such as low-income communities; the gay, bisexual, and transgender communities; and communities of color -- most acutely, the black community.
We have at our disposal the means to avoid many of these consequences. Antiretroviral medications (ARVs) provide us with the opportunity to seriously impede progression of the disease, especially when it is discovered in a timely fashion, to prevent most of the complications and poor health outcomes associated with an AIDS diagnosis, and to dramatically reduce the number of AIDS-related deaths each year. For those with access to consistent, quality care and treatment, HIV can now be a chronic, manageable condition -- akin to diabetes or high blood pressure.
What's more, quality care and effective treatment for those currently living with HIV will significantly curtail the further spread of HIV. ARVs work by reducing the level of virus in a person's blood to extremely low levels -- and the less virus in the blood, the lower the chances of transmitting the disease. Recent studies show that the already-lower-than-generally-realized risk of contracting HIV sexually is reduced by up to 96 percent when a person's viral load is suppressed to undetectable levels. Not only is near-universal access to quality health care good for people living with HIV, but it is also one of the best prevention tools we have.
The positive effects of the ACA and the near-universal access to health care it will provide to people living with HIV by 2015 are not just theoretical. Massachusetts, where health-care reform similar to the ACA was enacted years ago, experienced a 37-percent reduction in new HIV infections from 2005 to 2008, while the rest of the country experienced an 8-percent increase. And Massachusetts's age-adjusted HIV/AIDS death rate is almost half the national average (2 percent vs. 3.7 percent). These statistics, and the improved circumstances they describe, foretell what the nation can expect when the ACA is fully implemented.
When viewed through the prism of the HIV/AIDS epidemic, the argument for the constitutionality of the ACA's minimum coverage requirement (or "individual mandate") is relatively simple. Congress has the power to address the exclusion of a particular group -- specifically people living with HIV, but more broadly anyone with a pre-existing condition -- from a market that operates in interstate commerce. But the ban on preexisting condition exclusions will not work without the accompanying individual mandate, which requires every American to become a part of the health-care insurance pool regardless of their current health status. For that reason, the individual mandate is a necessary and proper means by which Congress can effectuate its clearly constitutional power to regulate an interstate market under the Commerce Clause.
Full implementation of the ACA is absolutely critical in our battle against HIV/AIDS. Public health authorities are already talking about the "end of AIDS," meaning the ability to prevent a person's progression from HIV-positive to an AIDS diagnosis and the most detrimental effects of the disease. Let's hope the Supreme Court recognizes the constitutionality of the action Congress took when it passed the ACA, which will similarly prevent our nation's broken health-care system from going from bad to worse -- not just for people living with HIV but for all of us.
For a more detailed explanation of the legal arguments discussed above, read the friend-of-the-court brief submitted by Lambda Legal on behalf of 16 HIV advocacy groups, which was subsequently endorsed by 130 more groups.