by Sue Saltmarsh
Over the course of the almost five years it’s taken for implementation of the most anticipated provisions of the Affordable Care Act (ACA), we’ve learned many new terms—individual mandate, medical loss ratio, high-risk pool, essential health benefits, to name just a few. And we’ve also heard about “cherry-picking,” the practice of insurance companies to reject the elderly and already-sick in favor of insuring the “cherries” - young, healthy people. They used to do this by rejecting those of any age with “pre-existing conditions,” by creating disparities between men and women, and by dropping people when they got sicker or had a medical crisis.
The ACA has supposedly outlawed those criteria and made up for that kind of cherry-picking with the individual and employer mandates which make it necessary for every person to have health insurance and every employer with 50 or more full-time employees to provide coverage for them.
But wait! In July 2013, the employer mandate was “delayed,” thanks to businesses complaining so much about the cost of insuring their employees. So the reports of employers cutting employees’ hours so they’d only be part-time and wouldn’t have to be insured, if ever true to begin with, finally stopped.
The individual mandate, sickeningly called the “individual shared responsibility provision,” however, is firmly in place, though it has nothing to do with “shared responsibility” and much to do with increased profits for the insurance companies. The penalties that “irresponsible” individuals would have to pay for remaining uninsured increase from $95 the first year to $325 in 2015, to $695 in 2016 and beyond. Even at the 2016 rate, you’d pay less for the penalty than you would for two monthly premiums if you make 400% of Federal Poverty Line (FPL), which would be $44,680 for one. So there might be many “cherries” out there who prefer to pick the penalty than to have their pockets picked.
Forced out of the cherry picking business, insurers are now moving to “lemons,” especially HIV-positive ones. This time, though, dropping them is the preferred action. According to the National Journal, the ACA “prohibits insurers from denying coverage to individuals with preexisting conditions, but some companies may be limiting their prescription drug offerings to steer HIV patients to other plans.”
"We're seeing policies in place by insurance companies that certainly look like they are intended to make plans look less attractive to patients with HIV," said John Peller, vice president of policy at AIDS Foundation of Chicago, in the article.
There are two main concerns about this HIV “lemon-dropping”—“that companies aren’t offering single-tablet regimens (STRs) for HIV patients in their Quality Health Plan (QHP, the benchmark for ACA exchange plans) formularies,...and that there is a lack of transparency as far as what the plans offer to individuals with the disease.”
Though STRs are indeed expensive, there’s data that show that they reduce hospitalizations by 23% and medical costs by 17%, not to mention the much greater rate of adherence if people only have to take one pill once a day. Greater adherence equals suppressed viral load, equals less risk of transmission and fewer new infections. Much like syringe exchange programs, STRs provide a big bang for the buck, in treatment and also as a tool of prevention.
It’s no secret that I’ve suspected since 2010 that insurance companies would find a way around the axing of the pre-existing conditions clause. I've predicted several times that instead of discriminating against the people with the disease, they would begin to discriminate against the disease itself. I believe this is the first wave of that discrimination.
As someone who works with and cares about HIV-positive people, I’m horrified at the potential resurgence of the epidemic that this could cause. As someone living with a condition that requires me to take six medications two or three times a day, I wonder how long it will be before the drugs that alleviate the nausea associated with chemo and radiation are dropped from formularies or the drugs that control blood sugar without insulin injections or the blood pressure drugs that keep my throat from exploding.
Because whether we have HIV, cancer, diabetes, or primary biliary cirrhosis, to the insurance companies, we’re just lemons. I say it’s up to us to make the lemon-aid that will get rid of insurance companies and ensure that everyone gets the medications they need to stay alive. They want “individual shared responsibility?” We can do that too.
By all of us paying into a healthcare trust fund; by being responsible for ourselves and each other; by removing all financial barriers, including the absurdity of healthcare as something to be bought and sold on Wall Street; by ending racial and socioeconomic disparities; by making insurance companies a thing of the past; by freeing employers from the expense of insuring their workers; by never having to pay a premium, deductible, co-pay or co-insurance again—all of that is within our grasp with true universal healthcare. What more has to happen before we close our fists around it and don’t let go?
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