The Medical Catch-22: Marriage Equality

By: Marcus Hopkins, Blogger

The past four years have been, for many LGBT couples, exciting times – we’ve seen the expansion of marriage rights in 32 states (whether by court rulings, votes, or legislation), something that even a decade ago seemed a far flung ambition. But, as many of these couples are learning, with this newly granted access to legalized marriage, there could be some unintended consequences that may reshape the way both they and the healthcare advocacy community address access to healthcare.

For decades, couples have sought rights to marriage. In doing so, many of us who advocated for the right to legally marry rarely spoke of the legal ramifications that accompany that newly wedded status. While many couples may have already combined their finances prior to marrying, once the knot has been tied, those combined incomes can prove detrimental when attempting to purchase affordable healthcare coverage, and may outright disqualify certain people from accessing medications and treatments via various low-income assistance programs, such as the Ryan White Care Act, Medicaid, Medicare, ADAP, and various other Patient Assistance Programs (PAPs).

For over two decades, people living with HIV/AIDS have relied upon the assistance provided by these programs to treat their illness, receiving life saving medications to which they might not otherwise have access. With roughly 54% of the HIV/AIDS population living on incomes that fall slightly above or below the Federal Poverty Limit, these programs provide a vital service to those who are most in need.

These programs, however, often have relatively stringent income requirements that need to be met prior to gaining access – primarily, having an income that falls below certain upward percentages of the FPL (with an exact number being difficult to pin down, as it varies by state). For many people living with HIV/AIDS, there has long been the sad reality that, working too much will make medication (even with insurance) unaffordable, but working too little will leave them living lives of relative poverty.

This medical Catch-22 has been present in the HIV/AIDS community for the entirety the Ryan White Care Act’s existence; the difference between access to treatment can literally come down to dollars and cents, where even the slightest overage in income can leave someone without any viable options.

While realistic answers have rarely presented themselves on a Federal level, it was hoped that the expansion of Medicaid on a national basis would have eliminated many of those problems, shifting several patients from Ryan White over to Medicaid. However, as only 28 states have accepted the Medicaid expansion (or have received waivers for their own attempted programs), many patients were left in the lurch.

With further expanded marriage rights, some patients may find that their newly recognized legal status has effectively priced them out of the healthcare market – their combined incomes being too high to qualify, but not high enough to pay for coverage that allows for realistic co-pays on medications.

The Marriage Equality Map, July 2014

This may come as a shock to those who have come to depend upon these programs to gain access to treatment; the coverage they once relied upon, month after month, may no longer be available to them, once they file their Federal and state taxes, and have to report their spouses’ income, as well.

And that doesn’t even take the presence of children into account. Will minor children now be part of a “legal” family or “household?” With not every state offering (or having) expanded marriage rights, addressing these issues on the Federal level may be even more difficult.

What is troublesome, as someone who has seen what can happen when one “makes too much money” to be considered “poor,” is that there are no definitive answers, at the moment. Healthcare providers, professionals, and advocates (as well as the legal arm of this equation) cannot provide any solid answers, at the moment, because we are entering relatively new, and legally murky waters.

For sero-concordant and -discordant couples, the answers could be markedly different, as the costs for concordant couples will likely be exponentially more costly, with medications for both HIV and HCV being placed in higher tiers, meaning higher co-pays for both.

Right now, making any predictions would likely be a fool’s errand – how do we predict what we’ve not yet experienced? Unfortunately, while those of us in the LGBT community have much to celebrate, we must be cautious when moving forward into wedded bliss.

Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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