On May 29, 2014, the AIDS Initiative (TAI) and the National Health Law Program (NHeLP) filed a discrimination complaint with the Department of Health Human Services against four health insurance companies in operating in Florida: Coventry Health Care, Inc., Cigna, Humana, and Preferred Medical.

Each of these providers offers plans on the Florida insurance exchange that cover the cost of prescription medications for HIV. TAI and NHeLP allege that these companies violate the non-discrimination language of the Patient Protection and Affordable Care Act (ACA), specifically Section 1557, on the basis of disability. All four companies restricted coverage for HIV medications, including generics, to their highest tier of plans. Coventry provides a representative example: they require a $1,000 deductible followed by 40% copay. The other exchange plans operate along similar lines. TAI and NHeLP contend that these restrictions “unduly limit access” for HIV patients.

While the complaint filed by TAI and NHeLP may certainly have validity, especially in light of the fact that even generic drugs are restricted, this complaint points to a larger problem in the United States, not just Florida. The real problem to be addressed for most HIV/AIDS patients is a socioeconomic one. Not only are HIV/AIDS patients among the sickest in the exchange pools, but they are also amongst the poorest. The recent Express Scripts Exchange Pulse public exchanges report (April 2014) found that “85% of exchange plan members reside in areas where the household income is typically between $25,000 – $85,000.”

In 2013, the Kaiser Family Foundation assessment found that Medicaid covered 230,000 HIV-positive beneficiaries. The Centers for Disease Control and Prevention (CDC) found that 75% of HIV-positive patients live at or below the federal poverty level. The United States government’s statistics on the AIDS population shows that 63% of all HIV/AIDS patients are either black or Latino, the two demographics most heavily plagued by impoverishment.

While HIV and AIDS patients tend to be amongst the poorest, the drugs they require are some of the most expensive. Express Scripts’ report showed that HIV medications ranked #1 in both Specialty Drug Claims Volume and Top 10 Drug Classes for Total Claims Cost on the public health exchanges. The ACA made it illegal to discriminate against HIV-positive applicants seeking coverage; however, this doesn’t mean that insurance companies have any more incentive to cover these patients than they did before the enactment of the ACA. In fact, what has begun is a “race to the bottom” to avoid HIV-positive patients.

If all insurance companies are forced to provide coverage, then they will do everything they can to avoid sick patients and reduce their costs under the ACA. Ironically, despite its intent to expand care, the ACA actually takes away incentives to cover HIV/AIDS patients.

Because of high rate of transmission, HIV cannot be dismissed as a personal responsibility problem for the infected unfortunates to figure out alone. That mentality will only perpetuate the problem of the AIDS epidemic. The solution to this problem lies in the replacement of the Affordable Care Act with a cost effective alternative! Increasing competition in the commercial health market to bring down costs coupled with a total overhaul of Medicaid and the tax code is the first step.

This requires a crackdown on fraud and the adoption of a uniform tax credit for all forms of health insurance. This would incentivize the purchase of individual health insurance and greatly increase competition, thereby lowering the market price.

These provisions would generate the funds necessary to cover the HIV-positive subpopulation within Medicaid. Those HIV patients with the funds to pay for their own insurance would find it cheaper options on the commercial market due to the increased competition, while those HIV patients incapable of purchasing their own coverage would be protected by Medicaid. Approaching entitlement reform in this way eliminates wasteful spending while also protecting our society’s most vulnerable.

The AIDS problem poses a unique challenge to our society. What are our responsibilities as a community? How far should the government go in providing care? What does a responsible solution look like? What can be concluded is that the ACA is not the answer the AIDS community is seeking.