LGBT Older Adults, HIV and the Affordable Care Act by SAGE

SAGE ISSUE BRIEF

LGBT Older Adults, HIV and the Affordable Care Act

Estimates project that within the next few years, one in two people with HIV in this country will be age 50 or older—an epidemic that has disproportionately impacted lesbian, gay, bisexual and transgender (LGBT) people and people of color since its inception. Further, HIV infections are on the rise among older people, many of whom are dually diagnosed with HIV and AIDS. Affordable, quality health care is a key factor for preventing and managing HIV/AIDS. The Affordable Care Act—enacted in 2010— expanded coverage for millions of Americans, including LGBT people, older people and people with HIV. Yet the available evidence suggests that many people will continue to need support in navigating these new health options under ACA, including understanding how their HIV care has been affected by the insurance marketplaces and Medicaid coverage options in their states. This Issue Brief looks at HIV and aging among LGBT older people and what the ACA has done to support this population. Additionally, this brief offers information to help people with HIV understand their new health options and to support their overall health and wellness.

HIV and LGBT Older People1 The demographic face of HIV/AIDS is a graying one. Research shows that by 2015, one in two people with HIV/AIDS will be age 50 and older. Overall, the rates of HIV/AIDS among older adults 50+ have increased more than 61 percent from 2001 to 2007. This population includes long‐time survivors, newly diagnosed people (often late) and newly infected people. The advent of HIV medications in the 1990s has allowed many people to survive and age with HIV—a first for this generation. 1

For a list of citations, please visit SAGE’s website at http://sageusa.org/issues/hiv.cfm. 1

LGBT OLDER ADULTS, HIV AND THE ACA • © SAGE (SERVICES AND ADVOCACY FOR GLBT ELDERS), MAY 2014

SAGE ISSUE BRIEF Infections are on the rise among older people. The latest national data show that adults 50 and older account for 17 percent of all new HIV/AIDS diagnoses and 29 percent of all persons living with AIDS. Despite the rise in HIV infections among older people, few prevention efforts explicitly target older adults with age‐sensitive information and education. HIV/AIDS disproportionately affects LGBT people and people of color. Some studies have found that gay and bisexual men are 44 times more likely to contract HIV than other men, while African Americans and Latinos are 12 and 5 times more likely to be HIV positive than their peers. Transgender people are also at a high risk for HIV. HIV is also a concern for lesbian and bisexual older women. According to the Lesbian AIDS Project report, some lesbians, bisexual women and WSW engage in high‐risk behaviors for HIV transmission, including having oral sex without a protective barrier, sharing sex toys without a protective barrier and/or disinfecting them after use, and sexual play that involves the potential exchange of vaginal fluids. In addition, some lesbians, bisexual women and WSW have sexual histories with HIV‐positive men or intravenous drug users, and have self‐reported participating in sex work for money or drugs—behaviors and experiences that pose great risk for HIV/AIDS infection. Older adults are often not tested for HIV because of providers' misconceptions that they are no longer sexually active. Further, many LGBT older people often delay medical care for fear of discrimination. Our experience shows that medical providers are less likely to ask older patients about sexual activity— including numbers of sexual partners, using protection and other factors related to HIV/AIDS—due to their own discomfort as well as a common misconception that older adults are not sexually active. Research shows that heterosexual and LGBT older adults are sexually active well into their mid‐80s, with a 2007 national study showing 53 percent of adults age 65‐74 and 26 percent of adults age 75‐85 as being active with one or more partners.

ACA and LGBT Older Adults with HIV A NOTE ON THE OPEN ENROLLMENT PERIOD: “‘Open Enrollment period’ refers to the period of time during which individuals who are eligible to enroll in a Qualified Health Plan can enroll in a plan in the Marketplace. For 2014 coverage, the Open Enrollment period ended March 31, 2014. The Open Enrollment Period for 2015 coverage is November 15, 2014 – February 15, 2015. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events. You can apply for Medicaid or CHIP at any time of the year.” – HealthCare.gov 2

LGBT OLDER ADULTS, HIV AND THE ACA • © SAGE (SERVICES AND ADVOCACY FOR GLBT ELDERS), MAY 2014

SAGE ISSUE BRIEF The Affordable Care Act has expanded health coverage for millions of people nationwide, including older people with HIV, many of whom are lesbian, gay, bisexual and transgender. For example: For LGBT People. The ACA has a number of advantages for LGBT people age 50‐64 who do not have health insurance. Research shows that LGBT people are less likely to have health insurance, and the number of uninsured older people age 50‐64 continues to rise—from 3.7 million in 2000 to 8.9 million in 2010. Without insurance, many people delay care, which can exacerbate poor health. LGBT people of every age deal with significant disparities related to physical and mental health. For older people, poor health represents the cumulative effect of a lifetime of discrimination. The ACA prevents health insurers from denying coverage or charging higher premiums based on pre‐existing conditions, or a person’s sexual orientation or gender identity. This is a significant step toward expanding health care access for transgender people and people living with HIV/AIDS, who often face life‐threatening discrimination in coverage. For People Age 65 and Older. Most people age 65 and older already have coverage through Medicare, and so should not purchase insurance in the online marketplaces. However, the ACA has provisions that have improved the benefits available through Medicare, including adding a free annual wellness checkup with your doctor; providing a range of free prevention services, such as cancer and diabetes screenings; and more help paying for prescription drug costs. While you will not be shopping for insurance coverage in the online marketplaces, you should review your current health and drug prescription coverage through Medicare. Visit medicare.gov or call 1‐800‐Medicare for more information. Legal residents of the U.S. who are over 65, but who haven’t met the work requirements to qualify for Medicare, are eligible to shop for insurance through the online marketplaces. For People with HIV. All private health insurance plans offered in the Marketplace will offer the same set of essential health benefits. These benefits include areas of significant importance to HIV+ people such as prescription drugs, lab services and chronic disease management. ACA has already ended lifetime dollar limits on coverage of essential health benefits, cracked down on frivolous cancellations of policies and made it illegal to arbitrarily cancel health insurance just because the policy holder got sick. Beginning in 2014, insurers will not be allowed to deny coverage due to a pre‐existing health condition— an enormous benefit to HIV+ older adults. Yearly dollar limits on coverage of essential health benefits are also no longer allowed. All of this will make it possible for people living with HIV/AIDS to receive and maintain affordable health coverage. 3

LGBT OLDER ADULTS, HIV AND THE ACA • © SAGE (SERVICES AND ADVOCACY FOR GLBT ELDERS), MAY 2014

SAGE ISSUE BRIEF DID YOU KNOW? New research from the Kaiser Foundation has found that there are 200,000 people with HIV who could gain new coverage under ACA—through Medicaid expansion and the state Marketplaces—if all states were to expand Medicaid and if all people with HIV were in care.

What You Should Know about the ACA GreaterThan.org maintains an online portal of resources specific to helping people with HIV navigate their health insurance options under ACA. The site include an overview of benefits, including information tailored to people in different states who are uninsured, on Medicaid, Medicare, Ryan White or ADAP, employer insurance or private insurance. SAGE encourages you to visit this website to obtain up‐to‐date information to learn more about your choices under ACA. The text below is taken directly from the FAQ section at GreaterThan.org. Q: If I don’t currently have insurance, what are my options through Obamacare? If you are not offered health insurance through your or a family member’s job, or if you aren’t working, you can buy your own coverage from online insurance marketplaces (also known as “exchanges”) set up in each state as part of Obamacare—officially known as the Affordable Care Act (ACA). The purpose of these marketplaces is to make health insurance easier to get and more affordable. You can no longer be denied coverage or be charged more because of your HIV status. And insurers can no longer limit how much they’ll spend on your medical care —over a year or your lifetime. These are important changes for someone with HIV. If you are buying your own coverage in a marketplace, financial assistance may be available to reduce how much you pay for monthly premiums, and for what you pay out of your own pocket for medical care. In general, you may be eligible for financial help in the marketplace if you don’t have another source of coverage and you earn between $11,490 and $45,960 as a single person (income ranges vary depending on your family size). Another possible option for coverage is Medicaid. As part of Obamacare, states can choose to expand Medicaid to cover more people. This means you may now be eligible for Medicaid even if you were not before. If you live in a state that is expanding Medicaid and you earn about $16,000 a year or less as a single person (or $21,000 or less as couple) you likely can get coverage under the program. Also important for someone with HIV is that you no longer need an AIDS diagnosis or to be very sick or disabled to get coverage under these expanded programsNot all states are expanding Medicaid, but even if yours is not you may still be eligible.

SAGE ISSUE BRIIEF If you arre currently re eceiving finan ncial assistance from the R Ryan White H HIV/AIDS Proggram or the A AIDS Drug Assisstance Prograam (ADAP) yo ou are still req quired to havve health insu urance. Ryan W White and AD DAP will contin nue to be avaailable, but so ome of the services they cuurrently cover might have to be replaceed by insurance e. If you still need help payying for your ccoverage, eveen if you are b buying insuraance through the marketplaace or qualifyy for Medicaid d, Ryan White e and/or ADA AP may be ablle to help. n.org. For more answers to frrequently askked questionss, please visit GreaterThan

Additional Re esourcess Kaiser Fam mily Foundattion’s HIV secction offers po olicy analysis and informattion on a variiety of issues facing peo ople with HIV V, including cu urrent assessm ments on thee ACA and HIV V. >> kff.org/h hivaids ational Resou urce Center o on LGBT Agingg houses variious resourcees for older peeople with HIV, as SAGE’s Na well as for aging and lo ong‐term care e providers. > >> lgbtagingceenter.org A Center on H HIV & Aging investigates, d defines, and sseeks to addrress the uniqu ue needs and d The ACRIA challenges that older aadults of diverse populatio ons living withh HIV face as tthey age. >> acria.org/agiing alition has co ompiled various commentaaries on HIV aand aging among commun nities The Diverrse Elders Coa of color and LGBT peop ple and will re elease an origginal policy reeport. >> diveerseelders.orrg han.org proviides up‐to‐daate state‐by‐sttate tailored information tto help peoplle with HIV GreaterTh navigate A ACA and find the best plan n for their nee eds. >> greateerthan.org/ccampaign/obaamacare SAGE (Servvices and Advvocacy for GL BT Elders) 305 Seventth Ave, 15th Floor New York, NY 10001 247 212‐741‐22 sageusa.org lgbtagingce enter.org This issue b brief was supp ported by an educational ggrant from Jaanssen Therapeutics, Division of Janssen Prooducts, LP.