When the Affordable Care Act (ACA) was ushered into law in 2010, it prompted mixed feelings among the HIV medical community. The ACA was designed to expand insurance coverage for all Americans, but would it improve outcomes for low-income people living with HIV who already receive support through the federally funded Ryan White program?
Kathleen McManus, M.D., an infectious disease fellow at the University of Virginia School of Medicine, Charlottesville, set out to answer that question, focusing on people living with HIV enrolled in the ACA in her state. She presented her results at IDWeek 2015 in San Diego.
McManus and her colleagues found that low-income HIV-infected people enrolled in ACA health plans in Virginia had better health outcomes than those receiving care through the state's direct AIDS Drug Assistance Program (ADAP), in which people are typically treated at Ryan White clinics.
These results were "reassuring," said Pablo Tebas, M.D., a professor of medicine at the Hospital of the University of Pennsylvania. "People have been very critical of ACA -- half of the country wants to repeal it," he said. "So, it was reassuring to see that patients that were moved from Ryan White were doing well."
McManus examined health outcomes measured by rates of viral suppression among 3,933 PLWHIV enrolled in ADAP but also eligible for ACA insurance. Of these, about half enrolled in ACA health plans while the rest stayed on ADAP. At the end of the two-year study, 85.5% of people living with HIV covered by ACA achieved virological suppression, compared to 78.7% of those receiving medication through ADAP.
Even before the ACA passed in 2010, "we [had] already been privileged to treat underinsured patients" with Ryan White funding, said McManus, speaking at a press conference at IDWeek. However, Ryan White funding only helps people access HIV care, she noted. She theorized that those enrolled in the ACA may have had better outcomes because they had more direct access to comprehensive health care services, such as diabetes management, colonoscopies and other routine care.
These results were especially remarkable considering the fact that Virginia is one of the 20 states that did not expand Medicaid through the ACA, McManus said. If Virginia had opted for Medicaid expansion, about 75% of the study cohort would have qualified, she noted.
"I think that [this] study was able to show that better use of dollars is still possible" despite the "political climate" in that state, said Carlos Del Rio, M.D., a professor of medicine at Emory University School of Medicine, who also spoke at the IDWeek press conference.
Under the ACA, the state of Virginia designed two different ways that HIV-infected people can receive care. They can either enroll directly in ADAP, which offers them treatment at Ryan White clinics and free medication paid for by the state. Alternatively, they can enroll in an ACA health plan and the state uses ADAP dollars to pay for monthly premiums, deductibles and copays.
Del Rio called this strategy "a wise use of resources." In other states people living with HIV have to pay their own premiums, which creates coverage gaps when they can't afford the payments, he said.
In fact, McManus said, recent studies show that about 66% of people living with HIV enrolled in Medicaid have achieved virological suppression. "We achieved better rates with ADAP and ACA," she said. "We need to spread the word that ACA results in better outcomes," she added.
Tebas pointed out that states have not yet lost Ryan White funding. However, as the ACA becomes more entrenched, it is possible that the federal government will defund Ryan White, and people living with HIV will lose resources like case management, drug addiction services and mental health services, he said.
Overall, the ACA will eventually be viewed as a positive change in the U.S. health care system, Tebas said. In the meantime, "we need to make sure the transition is safe for patients," he said.
McManus' study was a start, demonstrating that HIV-infected people in Virginia did well as they transitioned to the ACA. She plans to conduct follow-up studies to learn more about the barriers they face when trying to enroll in the ACA.
