Watching President Trump’s State of the Union address Tuesday night, my mind raced back to one of my patients, panting as she strung together a few words. “My difficulty breathing,” she paused, “has gotten worse in the last few weeks.” In her hospital bed, she looked gaunt and tired. She was struggling with homelessness and had stopped taking her HIV medications months ago, as she did not have insurance and could not afford the cost of her medications. As her doctor, I feared that she had a life-threatening lung infection, an unfortunate but preventable complication of her HIV.
In his speech, Trump made the proclamation that the federal government will implement a plan to end the HIV epidemic by 2030. The goal is laudable, and according to experts, potentially achievable. However, Trump’s efforts to dismantle the Affordable Care Act and his opposition to Medicaid expansion directly harm efforts to end the HIV epidemic. Simply put, reducing access to health insurance and, thus, needed medical care, reduces access to HIV treatment and prevention and moves us further away from envisioning an end to the HIV epidemic in the United States.
As it stands, the HIV epidemic is increasingly concentrated in Southern states, especially among populations such as gay and bisexual men and communities of color. Although the southern United States is home to 38 percent of the population, it now accounts for more than half of new HIV infections. Not coincidentally, the South also represents the region of the United States with the highest proportion of states that have not adopted Medicaid expansion. If more people living with HIV in the South had greater access to Medicaid as the ACA originally intended, some of these new infections would probably have been prevented.
The ACA not only increased insurance coverage for people living with HIV via Medicaid expansion, but it also introduced critical protections against preexisting conditions, including HIV. Since taking office, Trump’s administration has vigorously pursued efforts to dismantle or weaken the ACA and oppose Medicaid expansion. It has encouraged Medicaid work requirements, ended the individual mandate, cut ACA enrollment assistance and permitted new health insurance plans that can subvert several core protections of the ACA, such as denying insurance to those with preexisting conditions. As a result, in 2017, the number of uninsured Americans increased by 700,000 for the first time since the ACA went into effect.
This is all the worse because we now have the tools to end the HIV epidemic. Almost 40 years after the discovery of the virus, we have excellent treatment regimens consisting of a single daily pill that treats HIV and makes it untransmittable to others. Pre-exposure prophylaxis (better known as PrEP), another single daily pill, prevents HIV infection when taken correctly in those not yet infected but at risk. Advances in HIV surveillance allow us to pinpoint where and how the epidemic is changing, so that additional resources can be dedicated to disproportionately affected communities. But these medical advances cannot be shared equally if access to care is limited and inequitable.
The president’s supporters will probably counter that the ACA was untenable, as health exchanges were collapsing across the country. Senator Majority Leader Mitch McConnell (R-Ky.) said in 2017: “Prices are skyrocketing, choice is plummeting, the marketplace is collapsing.” It’s true that the ACA is imperfect, but such critiques ignore key facts. In 2018, there were no counties without at least one insurer in the ACA marketplace, and only 17 percent of exchange enrollees have a marketplace with only one insurer. More importantly, the Trump administration has actively conspired to hamper successful implementation of the ACA.
Late into the night that my patient with HIV arrived on my hospital floor, I spent more time at her bedside. I observed her rapid breathing slow, a sign that her respiratory muscles were tiring despite the antibiotics and antifungal medications I gave her. She was dying.
My patient’s eventual death was preventable, of that I am certain. She was without medical care and medications for far too long, and in that time, her body was consumed by HIV.
While Trump boldly promised an end to the epidemic, I hope he understands how deeply intertwined the promise of our HIV treatment and prevention tools are with access to equitable and affordable care. If his administration continues to limit vital access to health insurance and medical care, I fear that my patients and others living with or at high risk of acquiring HIV will suffer irreparably and the epidemic will march on.