Trump will have to stop sabotaging Obamacare if he wants to end HIV

In tonight’s State of the Union address, President Trump is expected to roll out a big, new health plan to end HIV transmission in the US by 2030.

That goal might sound far-fetched, but it’s actually entirely achievable. As several HIV and public health experts told me, we now have the tools — including well-established public health measures and medicines — to fully halt the epidemic, which currently affects more than a million Americans.

There’s just one big problem with Trump’s grand strategy: Since taking office in 2016, his administration has been undercutting the fight against the virus — most notably by sabotaging the Affordable Care Act and encouraging states to introduce work requirements for Medicaid.

To put it simply, the ACA was a “watershed moment in the [HIV] epidemic’s history,” as the Kaiser Family Foundation’s director of global health and HIV policy, Jennifer Kates, told me in 2017. The law was designed to get more people access to health care, including those who were traditionally denied coverage because of “preexisting conditions” like HIV, or who were driven out of the marketplace because their health care was unaffordable. And so under the law, the disease was no longer a barrier to health insurance.

The law also expanded access to Medicaid, the government health insurance plan for low-income Americans. And remember: More than half of people living with HIV in the US are low-income.

So it’s no surprise that the insurance rate for people living with HIV increased under the ACA, according to the Kaiser Family Foundation, in states that expanded Medicaid. The death rate from the virus also declined in those states.

But while the Trump administration hasn’t successfully repealed the health law, it has managed to undermine it. And this slow sabotage of Obamacare is expected to subvert the fight against HIV, said Kates, who is currently working on an analysis of the data. “The ACA has driven increased coverage [for people with HIV],” she said, “so the extent that it’s scaled back or restricted, it’ll likely affect coverage.”

To understand why the ACA matters so much for HIV, let’s go back to the days before the law was enacted in 2010.

Back then, Medicaid wasn’t an option for the many low-income Americans living with HIV because only low-income children and parents, and pregnant or disabled people, were eligible. This often placed HIV-positive individuals in a Catch-22: They were told to get on antiretroviral treatment as soon as they were diagnosed, to suppress the virus and its spread and prevent disability. But they could only apply for Medicaid when the disease had already disabled them.

The ACA changed Medicaid eligibility so low-income people with HIV could finally qualify. Though a 2012 Supreme Court ruling relegated the decision to expand Medicaid to the states, 37 states to date have accepted the federal funding to broaden Medicaid coverage.

“Medicaid is the largest program for people living with HIV. It’s the biggest federal financing for HIV care, so it’s not a small part of the HIV response — it’s a big part,” said Jeffrey Klausner, professor of medicine in the division of infectious diseases at UCLA Fielding School of Public Health.

Since 2016, the Trump administration has been quietly waging a war on Medicaid and undertaking measures that undermine its reach and effectiveness. As Vox’s Sarah Kliff has reported, that has resulted in the uninsured rate in America rising again.

For example, the administration has encouraged and allowed some states to introduce Medicaid work requirements. That means people with HIV don’t just need to be low-income to qualify for health insurance; they are also required to get a job — a demand some won’t be able to meet. In Arkansas — the country’s first Medicaid work requirement approved by the Trump administration and an HIV hotspot — nearly 17,000 people have already lost health coverage. Even if people can get medical exemptions from work requirements, Kates said, “They’ll face challenges getting those exemptions,” and, “any pullback in Medicaid access will affect people with HIV.”

In addition, the administration has cut funding for Obamacare enrollment, Kliff reported, so fewer people will know about their options for health insurance. They’re also rolling back important subsidies that have driven Obamacare premiums up, making healthcare unaffordable for some once again.

“The Trump administration spent its first two years trying to get rid of Medicaid expansion,” Gregg Gonsalves, professor of epidemiology at the Yale School of Public Health and a former HIV/AIDS activist, told Vox. “[And] Trump’s attacks on the Affordable Care Act are part of a broader assault on publicly funded health care, including Medicaid.”

There is some good news. We now have antiretroviral treatment that can suppress HIV to the point that it’s undetectable in the blood, so people on treatment are unlikely to pass the virus to others. We also have a drug — PrEP, sold by the brand name Truvada — that can prevent people at risk of infection from contracting the virus. Together with basic public health measures — like diagnosing cases and messaging on safe sex — ending HIV is truly within reach.

People need access to the health system to reap the rewards of these discoveries and to drive down infection rates. There’s one simple way to do that, HIV and public health experts say: expand access to Medicaid.

“New infections are concentrated in the southern US,” Jeffrey Crowley, Georgetown Law professor and a former director of the White House Office of National AIDS Policy, pointed out. “And it’s the part of the country that’s least likely to expand Medicaid.”

The details of Trump’s HIV plan are still murky. Broadly, the administration is expected to take a “treatment is prevention” approach by calling for greater use of HIV medications that reduce the risk of spreading the virus. They’re also expected to focus on communities in about 20 states with the most widespread HIV transmission.

But, said Gonsalves, “If Trump was interested in ‘ending AIDS,’ he’d have to support Medicaid expansion and fix the flaws in the ACA rather than tearing it all down.”