The Affordable Care Act's Impact on HIV

Despite the rocky rollout of the Affordable Care Act (ACA), an estimated 5 million people had purchased health insurance on the exchanges by late March, with another 2.4 to 3.5 million new Medicaid enrollees.^1,2

Although there’s no way to know yet how many of those are HIV positive, a recent report from the Kaiser Family Foundation estimates that about 50,000 of the 70,000 uninsured people with HIV who are currently receiving care, and 124,000 who are not in care, are eligible for Medicaid or insurance on the exchanges, with most of the latter eligible for subsidies.³

This access to health insurance for a population in which one in three people don’t have any, including 70,000 people currently receiving care, could have a significant effect on the course of the epidemic in the United States, possibly even contributing to the rise of first HIV-free generation in more than 30 years, suggests a series of articles in the March issue of Health Affairs. ^3-6

That’s because people with HIV/AIDS who have health insurance are more likely to be tested, treated, and remain in treatment. There are several reasons for this, explains Zachary Wagner, a doctoral student in health service as and policy analysis at the University of California-Berkeley and the lead author of one of the Health Affairs articles. One is that insurance subsidizes the cost of testing, so people are more likely to get tested (under the ACA, insured patients now pay nothing for testing). Another is that when patients are tested, they are typically already in a healthcare setting, which increases the likelihood that they will receive early care if they test positive. Finally, people with health insurance are far less likely to discontinue care than those without.⁷

Do We Still Need the Ryan White Program?

The majority of HIV advocates and researchers emphasize the continued importance of the Ryan White Program in providing funding for HIV care. The program, which currently serves more than 500,000 people a year, not only provides direct support for medical treatment, including drugs, but also supports the medical home model that all major guidelines recommend, as well as providing coverage for ancillary services like mental health, substance abuse treatment, housing, and transportation.

Opponents of the program say the ACA renders it obsolete. Yet, as a Kaiser Family Foundation analysis found, unless all states expand Medicaid eligibility, an estimated 18,000 people with HIV/AIDS will remain ineligible for Medicaid or subsidies on the exchanges. Overall, 43% of people with HIV, about 60,000, live in states that are not expanding Medicaid.⁸ Also, the ACA does not cover illegal aliens and those in prison.

In addition, traditional insurers do not provide funding for the kind of multidisciplinary care that Ryan White does, and many people who will be insured will still need help with copayments and deductibles. In Massachusetts, which implemented universal coverage in 2007, an increasingly greater portion of the program’s funds went to fill these gaps.⁹ A recent requirement from the federal government requires all insurers to accept Ryan White funds from HIV patients to pay for premiums on the exchanges.¹⁰

Evidence from California, which transitioned many uninsured people living with HIV/AIDS to Medicaid and another low-income health insurance program, also suggests that the Ryan White program will still be needed. Although 53% of the clients in Ryan White had transitioned to health insurance, caseloads remained the same.¹¹

President Obama’s budget calls for increasing funding for Ryan White by $4 million, although it also proposes eliminating funding for the part that serves women, infants, children, and youth with HIV/AIDS.¹²

The Ryan White Program was due for reauthorization in 2013. However, the bill remains stuck in Congress.

Give those uninsured individuals health insurance, however, and an estimated 603,000 more people will get tested by 2017, resulting in about 3,300 new diagnoses, according to Wagner’s study.¹³ But that estimate holds only if all states expand Medicaid; with just 26 states and the District of Columbia expanding their programs, the number of people getting tested drops to about 484,000 and the number diagnosed to 2,650.

Yet even with the missing state Medicaid expansion, the authors estimated that a fifth of those who are unaware of their HIV infection would gain access to health insurance.

“There are huge prevention benefits with testing,” said Wagner, “but it also allows more access for treatment and counseling,” exponentially increasing its preventive benefits.

As the authors of a commentary in the Health Affairs issue wrote: “How the ACA continues to be implemented, and how the Ryan White Program fits into that, will be key not only to the future of the more than 1 million people in the  United States living with HIV/AIDS but also to that of the thousands of people who stand to be infected if prevention benefits are left on the table. The possibility of a generation of Americans free of HIV may be in sight for the first time since the 1980s, but policy decisions today will determine whether it can become reality.”⁴

References:

1.    Mangan D. Obamacare Enrollment Tops 5 Million. CNBC. March 17, 2014. http://www.cnbc.com/id/101501133. Accessed March 21, 2014.
2.    Avalere. Avalere Analysis Finds 2.4 Million to 3.5 Million New Medicaid Enrollees As a Result of the Affordable Care Act. (2014) http://avalerehealth.net/expertise/managed-care/insights/avalere-analysis-finds-2.4-million-to-3.5-million-new-medicaid-enrollees-as. Accessed March 21, 2014.
3.    Kates J, Garfield R, Young K, et al.Assessing the Impact of the Affordable Care Act on Health Insurance Coverage of People with HIV. Kaiser Family Foundation; (2014).
4.    Goldman DP, Juday T, Linthicum MT, et al. The Prospect Of A Generation Free Of HIV May Be Within Reach If The Right Policy Decisions Are Made. Health Affairs (2014) 33:428-433.
5.    Crowley JS, Kates J. The Affordable Care Act, the Supreme Court, and HIV: What are the Implications? Kaiser Family Foundation, September 2012.
6.    AIDS.gov. The Affordable Care Act helps people living with HIV/AIDS. June 2013; http://aids.gov/pdf/how-does-the-aca-help-plwh.pdf. Accessed March 21, 2014.
7.    Hughes AJ, Mattson CL, Scheer S, et al.Discontinuation of antiretroviral therapy among adults receiving HIV care in the United States.J Acquir Immune Defic Syndr (2013)
8.    Snider JT, Juday T, Romley JA, et al. Nearly 60,000 Uninsured And Low-Income People With HIV/AIDS Live In States That Are Not Expanding Medicaid. Health Affairs (2014) 33:386-393.
9.    Kates J.

Topics in Antiviral Medicine. (2013) 21:138-142.
10.    Chen C. Insurers Forced to Take Ryan White Funds for HIV Patients.Bloomberg News. March 14, 2014.
11.    Leibowitz AA, Lester R, Curtis PG, et al. Early evidence from California on transitions to a reformed health insurance system for persons living with HIV/AIDS. J Acquir Immune Defic Syndr. (2013) 64 Suppl 1:S62-67.
12.    McCroy W. Obama's HIV Budget Shows Commitment to Domestic Programs.Edge. March 18, 2014. http://www.edgeonthenet.com/health_fitness/hiv_aids/Features/156733/obama%E2%80%99s_hiv_budget_shows_commitment_to_domestic_programs. Accessed March 21, 2014.
13.    Wagner Z, Wu Y, Sood N. The Affordable Care Act May Increase The Number Of People Getting Tested For HIV By Nearly 500,000 By 2017. Health Affairs (2014) 33:378-385.