People with HIV who received health insurance coverage through a qualified health plan (QHP) from the Affordable Care Act marketplace had higher rates of viral suppression than people who only received HIV drugs covered directly through the AIDS Drug Assistance Program (ADAP), according to a new study presented at the IDWeek conference on Oct. 3 in Washington, D.C.
Researchers looked at data from a cohort of 7,776 people from three states (Nebraska, South Carolina, and Virginia) from 2014 through 2015. All three were states that had not expanded Medicaid at the time. Therefore, these states allowed for their state ADAP funds to be used to purchase private health insurance plans for ADAP clients from their state ACA marketplaces. Individuals could select whether they wanted the health plan or to continue to only receive direct coverage of their antiretroviral medications through the state ADAP. On average, 52% of all participants had QHPs. One-third of all participants were 45 to 54 years old, 66% were black, 75% had incomes below 138% of the federal poverty level, 50% had an AIDS diagnosis at baseline, and 20% were from rural areas.
Researchers found that 86% of people who were enrolled in an ADAP-funded QHP were virally suppressed, compared to 80% of people who were direct ADAP recipients. Researchers found there were no differences in achieving viral suppression when controlling for race/ethnicity, age, gender, income, or AIDS diagnosis. There were also no differences among risk groups -- men who have sex with men, injection drug use, or heterosexual contact. While there was lower enrollment in QHP among people in rural areas, living in rural communities was not associated with a lack of achieving viral suppression.
"The association of coverage through ADAP-funded QHPs and viral suppression was not different based on demographic factors such as race and ethnicity," said Kathleen McManus, principal investigator and assistant professor of medicine with the University of Virginia. "This is a key finding that the structural, system-level intervention benefitted people living with HIV across demographic groups and was not contributing to disparities in outcomes."
How would the care continuum be impacted if more people with HIV received comprehensive health coverage? The researchers estimate in this study that these three states would have to enroll 20 people in a QHP for every person who would become virally suppressed per year. They estimate if all 114,000 direct ADAP clients nationwide in 2017 moved to ADAP-funded QHPs, an additional 5,700 people living with HIV could achieve viral suppression.
"Once ADAP clients were enrolled in these QHP plans, they stayed enrolled," said McManus. "And given this, low-income people with HIV seem to find value in ADAP-funded QHPs, and they elect to continue to use that model of receiving state-supported HIV care delivery."
The AIDS Drug Assistance Program is funded from the Ryan White Part B program, which provides grants to states and U.S. territories "to improve the quality, availability, and organization of HIV health care and support services." And while this research shows how comprehensive health coverage may better serve people living with HIV, the program may have some challenges.
A recent report on Ryan White Part B and ADAP from NASTAD found that while ADAP-funded QHP enrollment grew 18% from 2013 to 2017, the Republican-led efforts to undermine the sustainability of the ACA marketplaces is taking its toll. Since efforts to repeal the ACA were thwarted by activists and public outcry, the Republican-controlled Congress and Senate in 2017 cut funding for public awareness campaigns about marketplace enrollment as well as funding for health care navigators. As a result, enrollment in the ACA marketplaces overall has slightly declined, leaving a disproportionate number of people with chronic illnesses (that are more expensive to treat) in many state exchanges. And with fewer government supports and fewer low-use healthier people signing up for insurance, more insurers are pulling out of the exchanges. In some states, there may be only one insurer in the marketplace altogether.
But this wasn't the way the ACA was originally built. The Affordable Care Act was initially designed so that people with HIV who were without health coverage would be able to get Medicaid through the expansion of the program, but a 2012 Supreme Court decision allowed for state governors to decide whether they would expand the program. Many Republican governors did not, including those in some of the places most impacted by the HIV epidemic, or with residents with higher rates of a range of chronic illnesses. A study by Kaiser Family Foundation found that Medicaid expansion was the biggest reason for uninsured rates of people living with HIV to decrease. But for states that didn't expand the program, some state AIDS directors used their ADAP funds to buy qualified health plans for people living with HIV who were uninsured. Several studies have looked at the impact of this approach on viral suppression rates in individual states, but this is the first research study to look at different states together.
"States that have not expanded Medicaid should consider this intervention to increase viral suppression in their states," said McManus. "This evidence-based intervention could be a part of the United States [plan] to end the HIV epidemic."