While the GOP celebrates its recent political victory of passing its massive tax code overhaul, the most vulnerable among us, especially LGBTQ youth of color living with HIV/AIDS, are at significant risk as a result of the new legislation—among other recent policies—according to advocates and researchers in the health care realm.
In particular, the tax bill’s repeal of the Affordable Care Act individual mandate provision, which U.S. Senate Republican leader Mitch McConnell gleefully claims “takes the heart out of Obamacare,” could jeopardize access to health care for many across America. The move, which eliminates the penalty for not having coverage, will likely deter younger, healthy people from applying, thus creating a sicker pool of enrollees who do not have insurance through an employer. Experts say this is likely to destabilize the market, leading to higher premiums and about 13 million more uninsured Americans by 2027, according to the nonpartisan Congressional Budget Office.
Health care policy advisers such as Larry Levitt, senior vice president for health reform and senior adviser to the president at the Kaiser Family Foundation, said the repeal would impact the ability of people living with pre-existing conditions such as HIV/AIDS to purchase insurance. “With no individual mandate, premiums will certainly go up. Healthy people may be able to buy loosely regulated insurance like short-term plans with lower premiums, but those plans don’t cover people with pre-existing conditions.”
Beyond the hardship of higher premiums, AIDS policy organizations say the bill’s $1.5 trillion in tax cuts is unsustainable given the soaring deficit. They contend this will invariably lead to the cutting of federal programs such as Medicare and Medicaid, which are vital to LGBTQ Americans.
In a statement against the tax legislation, the Federal AIDS Policy Partnership predicted “the loss of revenue, coupled with growing federal deficits, will force cuts to the healthcare and safety-net programs that people at risk for or living with HIV count on to stay healthy.” LGBTQ Americans are particularly vulnerable as they are more likely to be uninsured. In 2017, the Center for American Progress found that about 15 percent of LGBTQ Americans were uninsured, compared to 7 percent of the overall population.
Those potentially most affected as the system starts to fray are among the country’s most marginalized: “The 16- to 24-year-old African American transgender woman who is unemployed because there are so few federal and state-level protections for employment discrimination for transgender people,” says Dr. Brandon Hill, an HIV researcher and executive director at the Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health at the University of Chicago. “These are people who already bear the burden of almost all negative social and economic outcomes in our country.”
David Blumenthal, president of the private health care policy organization Commonwealth Fund, described how reverberations from the tax legislation could ultimately jeopardize the health of Hill’s vulnerable youth: “By decreasing after-tax incomes for low-income and middle-income Americans, the tax bill could also adversely affect health outcomes for these groups, and increase health disparities between low- and high-income Americans. To the extent that LGBTQ youth of color are more likely to have low and middle incomes, they could be negatively affected by the tax bill through this mechanism as well.”
Hill sees the young black and Hispanic clients in his program as particularly at risk, citing their elevated risk for HIV. He points to a stunning Centers for Disease Control and Prevention statistic from 2016: If current trends continue, one-half of black men and one-quarter of Latino men who have sex with men in the United States will be diagnosed with HIV in their lifetimes. Youth aged 13 to 24 accounted for more than 1 in 5 diagnoses in 2015 and were the least likely out of any age group to be linked to care and have a suppressed viral load. The 2015 U.S. Transgender Survey reported that nearly 1 in 5 (19 percent) of black trans women were HIV positive.
Hill’s center is on the South Side of Chicago, near underserved neighborhoods. He has a very personal view of the city’s HIV epidemic, working with young people of color who are living with the virus and those who are HIV negative but at significant risk for the disease, including those who are homeless or engaged in survival sex work. Hill’s team is focused on help for those teens, efforts built around the cornerstone of his research—addressing such factors as unemployment, unstable housing, unequal access to quality education, and access to affordable health care.
He views funding for such vital HIV/AIDs social services as imperiled under President Donald Trump’s administration: “I think it sends a terrible message from the federal government down to these young, LGBT people of color that there’s like a level of insignificance.” A look at the 2018 budget provides grist for that worry. According to Newsweek, Trump has sought deep reductions in several key HIV programs, including $150 million on HIV/AIDS at the CDC.
One such program that has come under attack for budgetary cuts is the Ryan White HIV/AIDS Program, the single largest federal program designed for people living with HIV in the U.S. It works to provide HIV care and treatment services to more than a half-million people each year. Sean Bland, a senior associate at the O’Neill Institute for National and Global Health Law, devotes much of his work to engaging policymakers in support of sustaining and adopting Ryan White. During the course of his work, Bland has seen certain barriers to health care, particularly for Latino LGBTQ youth, which he views as symptomatic of policy moves directed at undocumented individuals.
“With respect to the current administration’s immigration policies in terms of rolling back DACA and scaling up enforcement actions—these things could have a very chilling effect on these individuals accessing health care in a general sense, but also their willingness to access HIV treatment and prevention,” Bland said. The decision to forego care often centers on the concern that either the person seeking treatment or a family member will experience immigration consequences as a result of offering up personal information at a clinic.
Being able to dispel such worries while informing young people about prevention and treatment of HIV is vital. Yet some advocates contend that the Administration is actively choosing to undermine the expert advice from the very people who are working in the field. Among them is Scott Schoettes, a Chicago-based HIV project director at Lambda Legal, which advocates for LGBTQ people and people living with HIV. Schoettes resigned from the Presidential Advisory Council on HIV/AIDS last June with five other experts over Trump’s perceived lack of a strategy to address the ongoing epidemic. Trump fired the remaining members without warning last December—and as of this writing had no plans to replace them.
Schoettes disputes the oft-touted argument that the council members were fired as a matter of course to make way for a new president’s appointees: “When Obama came in, yes, he replaced people on the council but he did it because he had a plan, he had an agenda, and he wanted people in place to help him execute that agenda. Here it happened because some of us resigned and then some of the remaining members were critical or voicing concerns. It became about getting rid of people because you don’t want to hear the concerns.”
Another former member of the council, Gabriel Maldonado, is also the founder of TrueEvolution, which works primarily with black and Hispanic LGBTQ youth in Southern California to address homelessness and improve access to care for those living with HIV/AIDS. Long before being let go last month, Maldonado says he was deeply dismayed when the council’s recommendations for prevention and education for the types of kids he serves were seemingly disregarded by the Trump administration. His concern, however, revolves as much around the administration’s “traumatic rhetoric” as its policies. He cites comments surrounding Trump’s failed attempt to ban transgender troops from the military as an example.
“What does it do to the self-worth of my community when comments from the senior-most leadership in government belittle, marginalize, and attack them for who they are? The damage done to the psyche of young kids—the clients we are trying to encourage to engage in the public health system for prevention and HIV care—that will last for generations,” he said.
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