The Affordable Care Act and Women in the US

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The Affordable Care Act (ACA) was signed into law in the US by President Obama in 2010. Many of the health care and health insurance changes the ACA calls for are particularly important for women living with HIV (HIV+). Almost all of the changes have now gone into effect. For a timeline of scheduled changes, click here.

Why Is the ACA important for HIV+ women in the US?

In the past, people living with HIV have had a difficult time getting access to the care and treatment they needed. People living with HIV were often charged higher rates because they were HIV+. Some were denied coverage altogether because they were living with HIV. The ACA stops insurers from denying coverage and charging more for coverage for those with pre-existing conditions like HIV.

Before the ACA, HIV+ people with low incomes had a more difficult time accessing Medicaid. Medicaid is a program that is funded jointly by both federal and state governments and handled separately by each state. It is the government program that provides health coverage to low-income people. However, many HIV+ people with low incomes have not qualified because people needed to be both low-income AND fit into one of several qualifying groups (e.g., pregnant women, children, parents with dependent children, and people with disabilities) to qualify for Medicaid.

Because of these requirements, many HIV+ low-income women without children unfortunately had to get a diagnosis of AIDS in order to be considered disabled and qualify for Medicaid. Many states have chosen to expand their Medicaid coverage, making it easier for HIV+ low-income women to get access to care. However, some states, including several with the highest numbers of people living with HIV, have chosen not to expand their Medicaid coverage. For more information about Medicaid, please click here.
 
Women often feel the burden of health care costs more than men. Generally, women earn less than men. In addition, most HIV+ women have children or others living in their household who need care. It does not help matters that insurance companies have often charged women more than men for the same health insurance and have been able to list pregnancy as a pre-existing condition (also a cause for charging more or refusing coverage altogether). In combination, these factors have made it especially difficult for HIV+ women to get the care and treatment they need to stay healthy. 

The ACA provides for several changes that can dramatically improve the health of women living with HIV. These include:

Increasing access to care

The ACA:

  • Enables states to provide access to Medicaid for people living below 138 percent of the federal poverty level. In addition, Medicaid eligibility is now determined based on income alone; disability status will no longer be required. In a 2012 decision, however, the United States Supreme Court ruled that it was unconstitutional to require states to expand their Medicaid coverage. Therefore, states can choose whether or not to expand coverage. 

As a result, only some states have chosen to expand their Medicaid coverage and change their eligibility requirements through the ACA; others are still deciding. Many of the states that have decided not to expand Medicaid are also the states where the highest numbers of people living with HIV live.  Many states in the southeast region, for example, where the HIV epidemic is the worst, have chosen not to expand Medicaid.

  • Provides people without employer-sponsored insurance or Medicaid access to affordable health insurance marketplaces or exchanges in their state where they can buy health insurance. For those who have trouble paying, there are federal tax credits and subsidies (money the government gives you) for people with low and middle income to help make the insurance premium more affordable.
  • Stops insurers from denying coverage to those with pre-existing conditions (e.g., HIV, pregnancy, history of domestic violence)
  • Prevents insurers from charging more because you are a woman
  • Stops insurers from putting lifetime or annual spending limits on insurance benefits, which often affect those living with long-term illnesses like HIV
  • Helps to close the "doughnut hole:" the ACA will gradually close the gap in Medicare's prescription drug benefit (Part D) known as the "doughnut hole." The doughnut hole refers to the amount between total drug costs (what you and your plan spend in drugs) and a person's total out-of-pocket spending maximum for the year (this includes any co-pays, co-insurance, and deductibles). In addition, AIDS Drug Assistance Program (ADAP) payments for prescription drugs are now considered contributions toward the True Out of Pocket Spending Limit (TrOOP) for Part D, which means that people can move through the doughnut hole more quickly.

Preventive care

Preventive care refers to tests and screenings that help us find problems early and prevent more serious diseases from happening down the road. Many of the tests and types of care that fall under 'preventive' care are types of care that only affect women – things like birth control, pap smears, mammograms, and services for pregnant women.

The ACA required that all new insurance plans (those beginning on or after August 1, 2012) cover the following services with no cost-sharing (no co-pay and no deductible):

  • All methods of birth control approved by the US Food and Drug Administration (FDA), including the pill and the IUD. It is important to note that group health plans sponsored by religious employers do not have to cover birth control. Some religious employers do not have to provide birth control benefits.
  • Annual 'well-woman' visits. This means a once-a-year visit that includes a Pap smear. This is especially important for HIV+ women, since women living with HIV have an increased risk for cervical cancer and studies have shown that almost one in four HIV+ women in the US do not get their recommended yearly Pap tests.
  • Provide testing for the human papilloma virus (HPV), the virus that can cause cervical cancer
  • Provide screening for gestational (during pregnancy) diabetes for pregnant women, as well as breastfeeding counseling
  • Provide screening and counseling for domestic violence. This is also especially important for HIV+ women. We now know that HIV+ women are twice as likely to have experienced domestic violence compared to US women as a whole. In addition, HIV+ women who have experienced recent trauma are much more likely to be unable to negotiate safer sex and to fail their HIV treatment. Being able to identify and help women experiencing gender-based violence will be a huge step toward greater health for HIV+ women.
  • Provide testing and counseling for HIV and counseling for other sexually transmitted diseases (STDs)
  • Provide mammography screening every one to two years for women over 40 years of age
  • Provide depression screening and alcohol abuse screening and counseling. These are important for HIV+ women because any type of substance abuse reduces a woman's adherence to her HIV drugs and increases the chances that she will engage in unsafe sex. HIV+ women are also more likely than women in the general population to experience depression. Depression can cause women to seek care less often, not adhere to their HIV drugs, and have faster progression of their HIV.

You can learn more about how the ACA affects women living with HIV by looking at our list of additional resources. In addition, you can go to www.healthcare.gov to find insurance options, explore the insurance marketplace, learn about prevention and wellness benefits, and find out what is changing and when.

The Well Project would like to thank Jen Kates of the Kaiser Family Foundation for her assistance with this article.

Additional Resources

Select the links below for additional material related to public benefits and HIV.

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