As we begin to worry about the possibility of an Ebola epidemic taking hold in the United States, we must not forget the epidemic already firmly rooted here. The HIV/AIDS epidemic has raged for more than 30 years in this country with more than 1.1 million people in the U.S. living with HIV/AIDS and African Americans experiencing “the most severe burden of HIV,” according to the Centers for Disease Control. While a positive diagnosis no longer means guaranteed death, it does mean a life of expensive medications and care to manage the chronic disease. Lack of awareness and of access to care continue to help spread an infection that is relatively easy to avoid.
The arrival of the Affordable Care Act in 2010 improved health care options for people living with HIV/AIDS. Insurance coverage was finally possible because the law prohibited insurers from denying health coverage because of a preexisting condition. And that meant access to care and medications that prolong life and help slow the epidemic’s rate of transmission. The expansion of Medicaid would loop even more people with HIV/AIDS into care.
The imperative of doing so was vividly demonstrated in three maps presented by Lauren Banks of AIDS Alabama during a panel I moderated on HIV/AIDS at the Congressional Black Caucus Foundation legislative conference late last month. Right now, only 27 states and the District of Columbia have expanded Medicaid. The states that have yet to extend the federal government health care program are also home to some of the highest concentrations of HIV infections and those living with HIV/AIDS. To see those maps is to wonder why governors and state legislators in those states seem willing to deprive their citizens of health care and the life-prolonging and life-saving treatment that come with it.
The first map Banks presented showed the “rates of persons living with an HIV diagnosis, by county.” The heavy concentrations in the South, Northeast and urban areas are hard to miss. Those counties in the deepest red reported a rate of more than 384 persons per 100,000 living with HIV or an AIDS diagnosis as of 2010.
The second map Banks presented showed the data filtered to just show the rate of African Americans living with an HIV or AIDS diagnosis. The first thing you notice is that the areas of highest concentration on this map are almost identical to those in the map above. Those counties in the deepest red reported a rate of more than 1,061 persons per 100,000 living with HIV or an AIDS diagnosis as of 2010.
Now, look at the map below to see the stark and disparate impact of this epidemic on blacks and whites. Banks didn’t show this next map, but I found it while researching this post.
According to the latest data from the CDC, an estimated 50,000 people tested positive for HIV in the United States in 2011. African Americans “accounted for an estimated 44 percent of new HIV infections in 2010” and “accounted for 44 percent of people living with HIV infection in 2009.”
Other data from the CDC show the South had the highest percentage of new AIDS diagnoses (45 percent) at the end of 2010. The South had the highest percentage of people “living with an AIDS diagnosis” (40 percent) in 2009. And the South “accounted for 48 percent of the 17,774 persons with a diagnosis of AIDS who died in the 50 states and the District.”
And this brings me to the third map Banks presented during the panel, which shows the status of Medicaid expansion. You don’t need to be a geography whiz to see that the HIV/AIDS epidemic rages in the Southern states that are “not moving forward at this time” on Medicaid expansion.
Kaiser Health News (KHN) reported last March on a study which estimated that “nearly 115,000 uninsured, low-income people living with HIV/AIDS would be eligible for Medicaid if all states adopted the expansion.” But it added, “Of these, nearly 60,000 live in states not moving forward with the Medicaid expansion.” The KHN story notes that “About 70 percent of the group living in states not expanding Medicaid earn too little to qualify for financial help to buy insurance in the marketplaces created by the health law.”
Sylvia Burwell, the secretary of health and human services, is in talks with the governors of Tennessee, Utah and Indiana to expand Medicaid in their states. This is great, but there is no action in the states where it is needed most in the fight against HIV/AIDS. And an HHS official told me Friday that the agency has “worked with both Democratic and Republican Governors to be flexible so they can design a solution that works best for their states and their low-income residents.” The official added, “As we approach open enrollment for 2015, we urge all Governors to help people both get covered and stay covered, and we are committed to working with all states to implement Medicaid expansion in a way that maximizes coverage options for uninsured residents.”
If the moral argument for the need to extend health coverage to all those who want and need it doesn’t hold sway then perhaps the economic one will. The ACA mandates full federal financing of a state’s Medicaid expansion. Starting in 2017, that 100 percent federal match will gradually taper to and remain at 90 percent by 2020. Thus, the remaining 23 states that haven’t done so are leaving money on the table that could help thousands of people living with HIV/AIDS to get health coverage, care and treatment for “a big disease with a little name.” Knowing that, it takes a special kind of callousness to continue to say no to those in need.
Follow Jonathan on Twitter: @Capehartj