EDITOR’S NOTE: This is the second article in the series on the Obama administration’s campaign to enroll lesbian, gay, bisexual and transgender citizens in Obamacare, which force private insurers to cover the high-risk population by distributing the burden to other citizens and away from government. The first story reported the indications the White House has an unspoken agenda of lifting the financial burden from a demographic that overwhelmingly votes Democrat.
NEW YORK – The government’s own statistics affirm that LGBT citizens are responsible for an enormously disproportionate share of health care costs, which now will be placed on the backs of healthy citizens under the Affordable Health Care Act, known commonly as Obamacare.
As WND reported, the Obama administration’s emphasis on enrolling the LGBT community in Obamacare strongly suggests it has an unspoken agenda of lifting the financial burden from a demographic that overwhelmingly votes Democrat.
Medical research has demonstrated the LGBT community is disproportionately susceptible to a wide variety of health problems aside from HIV/AIDS, including mental illness and suicide, alcoholism, drug addiction and substance abuse.
In a slide presentation titled “Out2Enroll: The Affordable Care Act and the LGBT Communities,” prepared for a Sept. 12 White House briefing on Obamacare and the LGBT community, the Johns Hopkins Bloomberg School of Public Health counted 8 million Americans as gay, lesbian or bisexual. With another 700,000 regarded as transgender, Johns Hopkins estimates about 2.84 percent of the U.S. population is LGBT.
Since the rise of the HIV/AIDS epidemic in the 1980s, Centers for Disease Control studies have shown that more than 60 percent of all HIV/AIDS infections – 63 percent in 2010 – are caused by homosexual acts between men.
The second most frequent cause of HIV/AIDS infection is the sharing of hypodermic needles among drug addicts.
The CDC estimates that currently there are about 1.1 million people in the U.S. living with HIV/AIDS. About 1 in 6 who are afflicted is unaware of it.
The statistics indicate the disease is disproportionately prevalent among African-Americans, with more African-American heterosexual women being infected by their bisexual male partners than in the white community.
“Gay, bisexual, and other men who have sex with men (MSM), particularly young black/African American MSM, are most seriously affected by HIV,” the CDC concluded in a study of new HIV infections in 2010. “By race, blacks/African Americans face the most severe burden of HIV.”
The CDC noted the estimated incidence of HIV has remained stable in recent years, leveling off at a rate of 50,000 new HIV infections per year.
“In 2011, an estimated 49,237 people were diagnosed with HIV infection in the United States,” the CDC reported. “In that same year, an estimated 32,052 were diagnosed with AIDS. Overall, an estimated 1,155,792 people in the United States have been diagnosed with AIDS.”
The cost of treating HIV/AIDS
The CDC estimates the cost of HIV/AIDS health care treatment in terms of the cost per quality-adjusted life year, QALY, gained by the treatment.
“The QALY is based on the number of years of life added by the intervention. Each year in perfect health is assigned the value of 1.0. Each year of less-than-perfect health is assigned a value less than 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, be blind or suffer from worse mental health, then the extra life-years may be given a value of less than 1 to account for this.”
The CDC points out a cost-effectiveness ratio of $50,000 to $100,000 per QALY gained has long been cited as a conservative threshold for intervention. That benchmark has increased over time, reflecting advances in modern health care. In 2010 dollars, the plausible range for a cost-effectiveness decision rule has risen to $143,000 to $388,000.
The CDC points out that treatment costs can vary widely and the cost-effectiveness of the treatment may not be a function solely of the annual program cost.
In the following example, the CDC points out that both programs A and B have the same measure of cost-effectiveness in terms of cost per QALY gained. However, Program B is more costly to implement than A. Investment in Program B, the CDC argues, “may nevertheless be justified depending on budgetary constraints and the ability to implement for the program in the population and setting considered.”
The CDC says the most recent published estimate of lifetime HIV treatment costs was $367,134, translated to $379,688 in 2010 dollars. The cost is on track to exceed $450,000 in 2014, assuming a straight-line 105 percent decrease in the value of the dollar over the entire period of analysis, 2010-2014.
The CDC estimated the annual average cost of HIV care was $23,000 in 2010 dollars, translated into approximately $30,000 in estimated 2014 dollars.
The CDC further notes the use of highly active antiretroviral therapy (HAART) since 1996 has significantly improved survival for persons infected with HIV. The most current estimated life expectancy from the time of infection to death is 32.1 years for a large dataset of persons in routine outpatient care in the current treatment era.
Using U.S. national HIV surveillance data, the CDC reports, studies have estimated the average life expectancy after an HIV diagnosis has increased from 10.5 to 22.5 years from 1996 to 2005.
Other estimates have placed estimates of life expectancy and the cost for health care treatment even higher for those infected by HIV/AIDS.
“An American diagnosed with the AIDS virus can expect to live for about 24 years on the average, and the cost of health care over those two-plus decades is more than $600,000, new research indicates,” the Associated Press reported in 2006. “The research found that the average annual cost of care is about $25,200 – nearly 40 percent higher than a commonly cited cost estimate from the late 1990s.”
With 1 million people in the U.S. currently estimated to be infected with HIV according to CDC estimates – anticipating a $500,000 lifetime heath care cost measured in 2014 dollars per HIV case – the U.S. can anticipate $500 billion in health care costs to treat HIV over approximately the next 20 years. The cost is expected to increase as more expensive HAART therapies are provided to increasing proportions of the HIV-infected population.
The estimates focus only on the cost of medications to treat HIV-affected individuals, not expenditures for additional health care services required. Other related costs, given the psychological stress of HIV/AIDS, include treatment of alcohol and substance abuse and mental illness. There are also reimbursable costs for case managers, adherence counselors, nutritionists, expanded access nurses and other social service providers who may intervene to help an HIV/AIDS patient cope with life.
By comparison, the federal government Centers for Medicare & Medicaid Services at CMS.gov estimates that U.S. health care spending in 2011 was about $8,680 per person, a total of $2.7 trillion.
“Delivery of HIV-related health care in the U.S. is expensive,” states one of the more credible analyses of the health care costs of treating HIV/AIDS, published in a peer-reviewed medical journal. “Given the potential increases in costs of therapeutic agents, toxicities and comorbidities due to HAART, and aging-related comorbidities, it is likely that the aggregate of HIV care will continue to increase for the foreseeable future.”
Health problems incident to LGBT
The slide presentation titled “Out2Enroll: The Affordable Care Act and the LGBT Communities,” prepared for the White House briefing on Obamacare and the LGBT community illustrated the degree to which HIV/AIDS infection correlates with a increased incidence of other health care needs.
The Institute of Medicine’s 2011 report “Leading Health Indicators for Healthy People 2020,” from which the above graphic was derived, listed on page 53 “disparities” in LGBT health, also described on the HHS “Healthy People 2020” website:
- LGBT youth are two to three times more likely to attempt suicide;
- LGBT youth are more likely to be homeless;
- Lesbians are less likely to get preventive services for cancer;
- Gay men are at a higher risk of HIV and other sexually transmitted diseases, especially Hispanic and African American men;
- Lesbians and bisexual females are more likely to be overweight or obese;
- Transgender individuals have a high prevalence of HIV/STDs, victimization, mental health concerns, suicide and are less likely to have health insurance than heterosexual or LGBT individual;
- Elderly LGBT individuals face additional barriers to health because of isolation and a lack of social services and culturally competent providers;
- LGBT populations have the highest rates of tobacco use, alcohol use, and illicit drug use of all other specific populations.
A 2013 report titled “Optimizing LGBT health Under the Affordable Care Act: Strategies for Health Centers,” co-authored by the Center for American Progress and the National LGBT Health Education Center at the Fenway Institute, a private Boston-based health education center with expertise in LGBT health research and care, linked the HHS “disparity” report and the efforts of Obamacare to address the health care needs of the LGBT community.
“To begin to overcome these disparities, HHS included advancing LGBT health as a goal in Healthy People 2020 and has funded The Fenway Institute’s National LGBT Health Education Center to provide federally qualified health centers with training and technical assistance around LGBT health care,” the report noted on pages 2-3.
“Now, with the operation of the state-based health insurance marketplaces and the introduction of new provisions for ensuring that insurance plans are comprehensive and of high quality, the Affordable Care Act is providing an unprecedented opportunity to improve the health of many LGBT Americans.”
A national HIV/AIDS strategy
On July 13, 2010, soon after the passage of the Affordable Care Act, the White House released the first comprehensive National HIV/AIDS Strategy for the United States. It had three stated goals: 1) reduce the number of new HIV/AIDS infections; 2) increase access to the full spectrum of available HIV/AIDS health care treatments for those affected; and 3) reduce HIV/AIDS related health “disparities” occurring disproportionately in the LGBT community.
A YouTube video, co-posted on the government website Aids.gov, explains President Obama’s commitment to the National HIV/AIDS Strategy.
“The United States will become a place where new HIV infections are rare and when they do occur, every person regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination,” the AID.gov website proclaims
A second YouTube video, also posted on the AID.gov website, articulates National HIV/AIDS Strategy's “vision statement” in the voices of people of various races, ages, "gender identities and sexual identities."
To the extent to which the Obama administration succeeds in enrolling LGBT citizens in guarantee-issue insurance offered by private companies, it achieves a largely unarticulated public policy goal of shifting the cost of providing expensive LGBT health care from Medicaid and other government-funded efforts such as the Ryan White HIV/AIDS Program.
The improvement in HIV/AIDS health care envisioned by the national HIV/AIDS strategy, therefore, is to be paid for not by redistribution from higher-income Americans to lower-income Americans, but from healthy Americans who will pay higher premiums to subsidize the cost of enhanced HIV/AIDS medical care to the infected community.
Yet, as simple as the idea may seem, the economic reality is complex.
“In addition to expanding Medicaid, the ACA prevents insurance companies – whether they are on the exchanges or not – from dropping or denying coverage or charging higher rates for people with pre-existing conditions such as HIV/AIDS,” noted a recent Pew Charitable Trust analysis of how the Affordable Care Act will impact people infected with HIV/AIDs.
“Currently, at least 30 percent of HIV-infected people are uninsured. That compares to 15 percent in the general population," according to a study from the Kaiser Family Foundation. "Until the ACA was enacted, private insurers often dropped people diagnosed with HIV, and it was difficult for people with the virus to purchase health insurance at an affordable price.”
Clearly, with private health insurers no longer able to exclude LGBT applicants from coverage or to charge higher rates, having a sufficiently disproportionate number of healthy non-LGBT individuals enroll in Obamacare is a pre-requisite if participating private health insurers are to be profitable.
The income-redistribution strategy confronts participating private health insurers with two possibilities of incurring catastrophic losses. Too many LGBT and/or HIV/AIDS-infected individuals might buy insurance on the exchanges, or too few who are not infected may be willing to pay the higher health insurance premiums that will now be required.
The same risk of catastrophic loss does not apply to the Affordable Care Act requirement that private insurers provide health-care coverage to lower-income Americans without risking underwriting.
Under Obamacare, low-income Americans will simply self-select out of participation in the private insurance offerings on the government-operated health exchanges, precisely because the only requirement to be covered by an Obamacare health insurer is the willingness and ability to pay the premiums quoted.
Despite the protestation of Democrats in Congress, the Obama administration did not design the Affordable Care Act with the goal of getting private insurance to a larger proportion of the uninsured poor, despite the subsidies touted in the law.
Unless government-provided subsidies paid virtually all the cost of private health insurance for the uninsured poor, the default for lower-income Americans under the Affordable Care Act remains Medicaid, an assumption the preliminary Obamacare enrollment numbers appear to be validating.