HIV Rates Are Surging in Georgia. The GOP Governor Is Blocking Patients from Medicaid.

Barry Sermons was diagnosed with HIV in 2003. In 2008, he lost his health insurance when the market crashed and his wife Roni lost her job. Sermons was able to cobble together care as a patient at a Ryan White clinic, which sees many HIV positive Georgians with no or limited health insurance. But then Roni was diagnosed with breast cancer.  

“She had a minor surgery and some radiation, and no chemo at that point. She went into remission for four years. Then it came back. By the time she died she was blind, radiation had burned up her optic nerve.” At the end of her life Roni was in a wheelchair, and required an around-the-clock caregiver. Since they could not afford to hire one, Sermons dropped everything to care for her. 

A few months after Roni died, Sermons lost his healthcare coverage again, this time due to a clerical oversight of an overloaded case manager. Sermons turned to the AIDS Drug Assistance Program, another supplemental service available to people living with HIV, but he found it “full of red tape.” 

Sermons recounts the many hoops he had to jump through to get signed up, “You had to have documents. So in order to get your documents, you had to have transportation to get back and forth home,” he told VICE News this year. “It took four visits back and forth to get those things. People who are not housed probably don't have access to documents.” After all that, people on ADAP have to get re-certified every six months. 

Even with all of the work Sermons did to get on ADAP, the only healthcare provided by ADAP is access to PREP and HIV treatment. It doesn’t cover treatment for comorbidities and other issues that commonly affect people with HIV. “Since I’ve been HIV positive, I have had my tonsils removed. I’ve had hernias. I’ve had wrist surgery. I’ve had thyroid cancer. I’ve had sinus surgery. And the AIDS Drug Assistance Program would not have covered those things,” Sermons told VICE News. “And as people are aging with HIV, what happens is they need other services. As we get older, we have other comorbidities. I also have chronic bronchitis and every six months or so, because of my HIV, I’ll get bronchitis.”

The obvious question, of course, is why Sermons doesn’t have coverage through Medicaid, which is designed to cover health care for low-income people. Being on Medicaid would mean Sermons, and other HIV-positive patients, wouldn’t have to scramble to patch together a health care plan from several different and inadequate services. But in Georgia, Medicaid doesn’t cover people with HIV. 

Last year, Georgia lawmakers made a bi-partisan attempt to make things easier by extending Medicaid benefits to people living with HIV. But Republican Gov. Brian Kemp vetoed the funding. The Governor continues to block Medicaid expansion under the guise of cost, while the state ran a surplus of more than $6 billion in 2022, and is on track for another windfall in 2023. Kemp has bolstered his popularity by turning surplus dollars into tax rebates for residents, while 47% of Georgians say they would rather see the excess put towards healthcare. The Governor is choosing to expand Medicaid on his own terms through Georgia Pathways to Coverage - a healthcare program that has drawn criticism for its work requirements and minimal eligibility. Under Kemp’s version of Medicaid expansion, Georgians like Barry Sermons would need to work 80 hours a month while also not making more than 100% of the federal poverty level. That’s $14,580 a year for one person.

Medicaid and Medicare, which a series of Democratic presidents including Franklin D. Roosevelt and Harry Truman failed to get Congress to pass, were finally signed into law in 1965, by President Lyndon B. Johnson. Medicaid was created as a source of healthcare for single mothers, their children, and disabled individuals, and over time the program has widened its eligibility. In the 1980s, people with AIDS received disability status, giving them much-needed access to care. In the 90s, states began to take advantage of 1115 waivers to extend coverage to people living with HIV. The Affordable Care Act absolutely revitalized HIV and AIDS care as we know it: PREP became affordable and attainable, and Medicaid expansion made healthcare accessible to low-income individuals with HIV in some states. 

In recent decades, there’s been life-changing innovation in the realm of HIV treatment: PREP can reduce HIV transmission by nearly 99%, new research and exciting breakthroughs offer paths towards stamping the virus out completely. But in the state of Georgia, low-income individuals who contract HIV are not entitled to Medicaid benefits. And experts say Republicans’ inaction on expansion is fueling the epidemic of new infection in the state. Medicaid remains the primary source of insurance for non-elderly people with HIV. 

“Unfortunately, poor people are being trapped in this cycle of not making enough money to qualify for federal subsidies to purchase their own insurance,” said Jeff Graham of Georgia Equality, touching on the lack of coverage in the state. Kemp’s Pathways program tightens the squeeze, “And then at the same time, here in Georgia you have to work 80 hours a month to qualify for Medicaid. We continue to have roughly half a million people in Georgia that fall into this coverage gap.” Individuals like Barry Sermons often get trapped in this gap. In addition to being very low income (making less than 100% of the federal poverty level), one must also have a disability, be carrying a pregnancy, be legally blind, need nursing home care, be 65 or older, or a child or teenager in order to qualify for Medicaid in Georgia. 

The controversial Pathways plan was green-lit under the Trump administration. Once in office, the Biden administration rescinded approval for Pathways. Kemp sued the administration, and won, and a federal judge allowed the program to continue. When reached for comment on if it plans to appeal the ruling, the Department of Justice said that it was unable to comment on ongoing litigation.

Gov. Kemp’s office initially projected that coverage through Pathways would not be available to many Georgians, then later changed its tune. “They thought that they would only be able to cover an additional 30,000-50,000 people. So even the Governor’s estimates were that it was going to be hard for a lot of people to qualify,” Graham said of Pathways, “I think that they have now upped their estimates - that they do think that it is going to be closer to 90,000 or 100,000 people. Not quite sure why they changed their estimate.” The Governor’s office did not respond when reached for comment on why they changed their estimate. 

On top of this strain, there is also growing concern that the assistance provided by ADAP and Ryan White clinics may soon be in jeopardy. There are currently no waitlists for treatment at Ryan White clinics, but the unwinding of the COVID public health emergency may change that. “We are anticipating that there are going to be some pretty big challenges, and it’s going to hurt a lot of people here in Georgia over the next year,” Graham said of the emergency’s end. It’s estimated that millions may be kicked off of Medicaid in the coming months. Once people lose coverage, they may overburden clinics as they seek out new healthcare options.     

Ryan White clinics and ADAP receive a good chunk of change from federal funding. Graham is concerned about the vulnerability of social services in the hands of Republicans looking to cut budgets.  Ryan White Part A is funding designated for cities, and covers 20 counties in Georgia. Ryan White Part B is funding provided to states and territories, and covers the other 139 counties in the state. “[We’re] growing increasingly concerned about what may happen in the next federal budget when Republicans have said that they plan on instituting a number of deep cuts. Is that going to affect Ryan White Part B? The AIDS Drug Assistance Program is [also] funded primarily through the government.“

Given the tenuous future these programs face, broadening Medicaid’s reach is urgent. Georgians are already paying for Medicaid expansion, Graham explained. “Georgia taxpayers are subsidizing Medicaid in the 39 states that have expanded it,” while not being able to take advantage of those same benefits themselves.

Scaling up Medicaid access would not only strengthen outcomes for people living with HIV, experts believe it would slow and potentially end the trend of hospital closures within the state. Additionally, it would improve maternal mortality rates, which are at crisis levels for Georgia’s black residents. From a financial standpoint, Medicaid expansion would save the state $53 million.   

And it would make things a whole lot easier for people living with HIV, like Barry Sermons. Accessing adequate healthcare has been an uphill battle for Sermons. But the lengths he went to allowed him to get to the place where he is today - happy, and hopeful. “I’m living healthy. I’ve had HIV for 20 years. I’m undetectable. And I'm recently remarried to a woman who is HIV negative. And because I’m undetectable - which means that my viral load is under 200 copies - there’s a thing called u=u. That means undetectable equals untransmittable. So I’m not afraid of infecting my new wife. And we are living our best lives.” 

But he can’t forget his past, or ignore the knowing nag that things need to be different. Sermons has become an advocate for people living with HIV, “so nobody else had to go through the challenges that I went through.” When asked if he could snap his fingers and change anything about the healthcare system, Sermons said, “I would make healthcare a human right.”