The fight to repeal the Affordable Care Act moves to the Senate after House Republicans pushed through a bill to replace it with a new plan that would slash Medicaid funding and reduce coverage for people with pre-existing conditions.
People living with HIV or other chronic conditions will be heavily affected, advocates predict.
"The American Health Care Act is cynical, cruel, and not befitting of a civilized nation, especially one with the resources of the United States," said Project Inform Executive Director Dana Van Gorder, referring to what some are calling Trumpcare. "We are extremely disappointed in the legislators who voted for this bill, ignoring the will of most Americans and the needs of middle and low-income individuals, especially those with serious illnesses."
Democrats breathed a sigh of relief in late March when Republicans canceled a vote on an earlier version of the American Health Care Act due to insufficient support. But some of the previous opposition came from conservative hard-liners who thought it did not go far enough in dismantling the ACA, also known as Obamacare, and the new version addresses their concerns.
"This amendment takes a bad bill and makes it worse," said Sean Cahill from Fenway Health in Boston. "If enacted, it would make it much more difficult for people with pre-existing health conditions such as HIV to obtain health insurance that is affordable. This amendment seems designed to make it harder to obtain coverage for health care, not easier."
The revised bill passed May 4 by a four-vote margin �" 217-213 �" with all but 20 Republicans voting in favor and all Democrats voting against. Several California Republican representatives wavered in the lead-up to the vote, but they all ultimately supported it after an amendment added $8 million to subsidize insurance for people with pre-existing conditions.
The Republican plan removes several ACA mandates and leaves decisions about cost and coverage up to the states. It would roll back the ACA's Medicaid expansion provision, which nearly two-thirds of states have taken advantage of, to be replaced with block grants.
The House bill revokes the mandate that individuals must carry health insurance or pay a tax penalty, and removes requirements that health plans must cover several essential services, including mental health care and maternity care. Government subsidies under the new plan would be based on age rather than income and would generally be lower.
The Congressional Budget Office estimated that the previous version of the AHCA could result in some 24 million people losing health coverage by 2026. The House passed the revised bill without a new CBO review.
The legislation will now go before the Senate, but senators from both parties have said they will not vote on the House bill in its current form and will instead create their own version.
Widespread opposition
Local and national patient advocacy and health care provider organizations generally opposed the legislation.
"The AHCA dismantles key health reforms that have been pivotal to ending discriminatory practices that previously locked patients with HIV out of the individual insurance market and that guaranteed access to coverage for key services, including prescription drugs and mental health and substance use treatment," said Dr. Wendy Armstrong, chair of the HIV Medicine Association. "By decreasing access to HIV care and treatment, the AHCA may worsen the HIV epidemic in the U.S. at a time when new infections were beginning to go down."
More than 40 percent of people living with HIV rely on Medicaid, according to Armstrong.
"For the first time in my life we could see a real path out of the HIV epidemic," writer and HIV activist Brenden Shucart told the Bay Area Reporter. "The end was right there, but the Republicans in the House just effectively voted to keep AIDS in America alive for another 30 years."
ACA repeal is expected to have a profound impact in California. State legislators are currently working on Senate Bill 562, which would provide universal single-payer health care for all residents.
"The House vote to pass the American Health Care Act undermines the ability of people living with HIV to access affordable health insurance and sadly perpetuates the health disparities faced by individuals here in California and in states across the country," said San Francisco AIDS Foundation CEO Joe Hollendoner. "We call on the U.S. Senate to reject the AHCA, and to protect Medicaid [and] Medicare provisions that lower the cost of medications, and coverage for Americans with pre-existing conditions."
San Francisco Health Director Barbara Garcia previously told the B.A.R. that the ACA has extended health coverage to approximately 133,000 San Franciscans.
Mayor Ed Lee had harsh words for legislators who voted for the bill.
"It is very disappointing to see the House of Representatives approve a bill that strips coverage from millions of people, punishes Americans with pre-existing conditions, attacks women's reproductive rights, and creates an unequal, two-tiered health care system," Lee said in a statement. "Repealing the ACA turns back the clock on health care progress, and will hurt the health, security, and economy of our city."
HIV funding spared
The AHCA vote overshadowed a bit of good news earlier this month, as the House and Senate agreed on a Fiscal Year 2017 budget that maintains funding for most domestic HIV and hepatitis programs.
The FY2017 omnibus appropriations bill contains $2.3 billion for the Ryan White HIV/AIDS program and $789 million for HIV prevention at the Centers for Disease Control and Prevention, according to the AIDS Institute. But the advocacy group expressed disappointment that only $34 million was allocated for hepatitis B and C prevention.
Proposed deep cuts to the National Institutes for Health did not make it into the final bill �" and in fact the NIH received a $2 billion increase for medical research. Planned Parenthood was also spared direct cuts, though language in the AHCA legislation still threatens the organization.
"The bill's $2 billion increase for the NIH is vital to keep our nation's medical research enterprise on track," HIVMA's Armstrong said. "In addition, we welcome the sustained investment in global health programs, including PEPFAR and the Global Fund, that are combatting HIV, TB and other infectious diseases and shoring up global health security and preparedness to respond to new infectious disease outbreaks."
"We also are pleased that the bill allows federal funds to support syringe service programs that reduce the spread of HIV and viral hepatitis among individuals who inject drugs and maintains federal funding for Planned Parenthood programs, which are the only provider of HIV, STI and HCV screening services in some communities," she added.