Due to the impact of the Affordable Care Act (ACA), also known as Obamacare, in just two years the proportion of people living with HIV in care covered by Medicaid increased from 36% to 42% and the proportion that were uninsured fell from 18% to 14%. Even greater improvements were seen in states that expanded Medicaid coverage.
However, these gains could be reversed -- with significant numbers of people with HIV losing coverage -- if the Trump administration's promised repeal of the ACA includes elimination of the Medicaid expansion option for states.
The data come from the Centers for Disease Control and Prevention's Medical Monitoring Project, a surveillance system of people who are engaged in HIV care. They were presented at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2017) and in a more detailed briefing from the Kaiser Family Foundation.
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Data for 2012 and 2014, before and after implementation of major ACA reforms, were compared. In each year, a nationally representative sample of facilities offering HIV clinical care was assessed. Within each facility, a representative sample of patients was asked permission to be interviewed and for their medical chart to be consulted. Each year, approximately 5000 patients took part.
Those taking part told the interviewers how they paid for their antiretroviral medications and what forms of health coverage they had. In the analysis, researchers classified individuals according to their primary payer -- private insurance, Medicaid, Medicare or other public coverage (including Tricare/CHAMPUS, the Veteran's Administration or city/county coverage).
An important limitation of the data is that it only includes people with HIV who are receiving care. A significant number of uninsured individuals are included, but it can be expected that people who do not attend care are more likely to be uninsured. (From 2015 onwards, the Medical Monitoring Project does include people out of care, but those data are not included in this analysis).
The analysis demonstrates that a crucial aspect of the ACA for people with HIV is the expansion of Medicaid to cover individuals below 138% of the federal poverty level (FPL), which has been applied by 32 states (including the District of Columbia). In these states, the only eligibility requirements are residency status and income. (138% of the current FPL for an individual is $16,642, whereas for a household of four people, 138% of the current FPL is $33,948. Those with annual incomes below these thresholds can get Medicaid).
But, in states that have chosen not to expand Medicaid -- which includes many in the southeast with a heavy burden of HIV -- many people with low incomes cannot get coverage. To qualify for Medicaid, individuals residing in these states need to be both low income and "categorically eligible," such as disabled or pregnant. Further, people with a household income below 100% of the FPL fall into the "coverage gap": They are eligible neither for Medicaid nor for subsidies to lower the cost of purchasing coverage through the Marketplaces.
Nationally, Medicaid coverage of people with HIV increased from 36% in 2012 to 42% in 2014.
In Medicaid expansion states, it increased from 39% to 51%. In these states, the proportion uninsured (of those attending care) fell from 13% to 7%.
All of these differences are statistically significant. The greatest improvements were seen in people below 100% of the federal poverty level.
In contrast, in states that did not expand Medicaid, there were no significant changes in coverage or in the proportion uninsured.
Improvements in coverage also appear to have contributed to improvements in clinical outcomes. In Medicaid expansion states, the proportion of people who are virally suppressed increased from 77% to 83%, with the greatest improvement seen in individuals with a household income below 100% of the FPL. In this group, viral suppression increased from 71% to 80%.
In non-expansion states, there was a trend towards improved viral suppression, but it was not statistically significant. Overall the proportion virally suppressed was 78% in 2012 and 81% in 2014; among those below 100% FPL, the figures were 73% and 78%, respectively.
These results have implications both for individuals' health and for public health. Lower rates of viral suppression contribute to new HIV infections.
The data also underscore the importance of the funding from the Ryan White HIV/AIDS Program in the ACA era. This can be used to fund services such as case management, transportation and longer provider visits that could not be provided under other coverage.
In 2012, 42% of interviewees said that aspects of their care were paid for through Ryan White, rising by 2014 to 48%. However, not all patients will be aware of funding received by their health facility from the Ryan White program, so this may be an underestimate. Larger increases in the use of Ryan White funds were seen in privately insured individuals and in people living in states that did not expand Medicaid.
"Overall, this analysis suggests that the ACA has had a significant impact on coverage for people with HIV in the U.S., due to Medicaid expansion," concludes the Kaiser Family Foundation. "To the extent that ACA repeal efforts include elimination of the Medicaid expansion option for states, most people with HIV who gained coverage would likely lose it unless states adopt alternative approaches to retaining the newly covered population in the program."