ACA Turns Four: Recognizing Successes and Looking Ahead

By Xavior Robinson, Senior Manager, Health Care Access, NASTAD

Signing of the ACAMarch 23 marked the fourth anniversary of the Affordable Care Act (ACA). While it is undeniable that the ACA’s inaugural open enrollment period has had its share of challenges, it is important to recognize that the movement to ensure that all Americans have equitable access to health care transcends the technology failures of Over the past four years, state HIV/AIDS programs have worked to adapt and innovate to meet needs of people living with HIV and co-occurring conditions in our evolving health care landscape. Through the use of innovative solutions (see Raising the Bars), support from colleagues and staff, and an enduring commitment to the broader public health imperative presented by HIV, state AIDS directors have leveraged the ACA to achieve remarkable results, including:

1. Overcoming Glitches.

State HIV programs strengthened partnerships and formed new ones to engage eligible clients into coverage. Most HIV programs directly delivered or collaborated with community-based organizations to provide in-person enrollment assistance to clients through the patient navigator program and certified application counselors. In the face of glitches many programs sustained enrollment via mail and telephone.

2. Maximizing Insurance Purchasing Programs.

Over the past four years, programs have worked to build and ramp up insurance purchasing programs to assist clients with the costs associated with newly available private insurance coverage. Most recently, HIV advocates (including NASTAD and our members) successfully advocated for a federal regulatory requirement that health insurance companies that offer QHPs accept third-party payments from Ryan White Programs. This victory protects health insurance coverage for tens of thousands of people living with HIV who will rely on Ryan White Program insurance purchasing programs to afford their coverage.

  • Looking ahead: State HIV/AIDS programs are using lessons learned from the first year of open enrollment to inform activities aimed at increasing access to private insurance coverage for eligible clients in November of 2014, including coordinating across Ryan White Programs to fill remaining affordability gaps and advocating for federal protections to ensure that coverage is affordable. 

2. Facilitating More than 16,000 Enrollments. State HIV programs have facilitated the enrollment of more than 16,000 people living with HIV into Qualified Health Plans and expanded Medicaid and continue to enroll clients as the first open enrollment period comes to a close at the end of March.

  • Looking ahead: State HIV programs are developing mechanisms to track client eligibility and enrollment into coverage options, monitor QHPs for compliance with the ACA’s consumer protections and market reforms, and report any implementation challenges.

We want to hear from you! Use the comment box below to share your top three ACA-related victories during open enrollment.

  • Tim Barrus

    Thank you for this piece on the ACA. It is very interesting. One can only surmise that in regions such as the one I live in — Appalachia — there will be an upsurge in patient enrollment with community health centers. The impoverished are not well-served, and then top layers of government wonder what went wrong. I would argue that what went wrong is far, far, far more endemic than a computer glitch. I would suggest that patients in community health care settings are treated with enormous contempt by the very agencies funded to serve them. I would also argue that such health care agencies are allowed to operate while being in violation of every federal licensing requirement in existence. Thusly what gets delivered to the poor is below even substandard health care. You get what you pay for. But not in the case of health care for the poor. The tax-paying poor are given health care that is dangerous.

    The definition of contemporary health care cannot omit the reality of medication. This is not the dark ages. The pharmacy at the community health center that I go to here in Appalachia makes up its own rules, its own regulations, and its own operating procedures, and, quite frankly, they are in blatant violation of every federal guideline in the book. Oversight might be top-heavy, as this clinic would maintain, but reality does not agree. Community Health Centers are allowed to create their own standards, their own idiosyncratic measurements, and their own rules and regulations as they regard such things as medication delivery. The federal government only provides oversight on paper. In reality, the poor pay the price.

    One would think the federal government, especially the DEA and the FDA, would take oversight seriously. But no. One example would be in the area of pharmaceutical management. The issue is side effects. On paper, patients have the right to a certain level of access to information. This means a team approach. In that paradigm, the pharmacist plays an important role. Nevertheless, there are Community Health Center pharmacies that continually remain out of compliance which is DANGEROUS. The Community Health Center pharmacy that I myself use won’t even take phone calls from patients. We are not allowed to call them to ask about side effects from medications we depend on. This is what I mean by out of compliance. This is what I mean by oversight. This is what I mean by substandard. This is what I mean by the poor (especially in Appalachia) being targeted by discrimination, and stigma.

    I was from the beginning, and continue to be an avid supporter of the ACA. The problems are deeper than the ACA. The problem is a health care system that does not CARE. And it can get away with doing whatever it wants as they build their own version of what health care ought to be. Here, in Appalachia, that system is patriarchal, arrogant, and sees the patient as the enemy. We are not allowed to call the pharmacy when the medications that have been prescribed (and ironically paid for) are interacting. We are not allowed to consult with a pharmacist when a doctor is not available to us to discuss side affects. We are not allowed to question why any particular medication has been omitted by the pharmacy that decides what is best versus a doctor deciding what is best.

    The patient is continually and systematically informed that: WE FORGOT TO ORDER THAT COME BACK ANOTHER DAY.

    Another day means gas, mileage, mountain roads, frequently snow, closed roads, and very real obstacles that prevent the patient from receiving the prescriptions he has been prescribed and which have been paid for. We live with a system that makes up its own rules. So you overcome each obstacle to finally arrive at a pharmacy where you are not allowed to speak to a pharmacist, where they still don’t have your medication, and, in fact, WE FORGOT TO ORDER IT is what we are told time and time again.

    Let us put this paradigm into the pharmaceutical landscape of HIV.

    WHY should patients even get tested when they cannot get the meds because a public health pharmacy FORGETS to order medication. Again, medication that is paid for.

    If you can’t get treatment, why get tested.

    Only the poor can’t get treatment, and no one asks: why get tested.

    The PR rhetoric that maintains improvement has been made within the context of public health does not apply to Appalachia.


    No one knows.


    Because no one cares.

    The ACA is a great idea. But it is only an idea. The reality is that the poor and the sick get what they pay for. The reality is that federal regulations and operating management rules don’t mean anything. The reality is that poverty is endemic, and we still can’t consult with anyone (except poison control who know nothing about HIV meds which are very, very powerful) concerning side effects because we are not deemed worthy of a system that might help sustain us.

    In the end, it’s back to discrimination, stigma, and ignorance. And this is why there IS such a place as Appalachia.