Impact of the Affordable Care Act's Medicaid Expansion on HIV Care

The Kaiser Family Foundation released the first national estimates regarding the Affordable Care Act’s (ACA) Medicaid expansion, which were found to drive a nationwide increase in coverage for individuals living with HIV.

The brief, released on Tuesday, was based on an analysis of data from the CDC. Prior to the ACA, many individuals with HIV faced limited access to insurance coverage due to several challenges, including high cost, Medicaid eligibility limitations, and pre-existing condition exclusions.

Before the implementation of the ACA, insurance companies had the ability to deny coverage based on pre-existing conditions or perceived future conditions, including HIV, which was considered an uninsurable condition. According to KFF, most HIV-positive individuals were effectively barred from the individual market.

Even if patients could obtain private insurance, more often than not, it was prohibitively expensive because rates varied by health status and other factors. Furthermore, annual and lifetime limits on coverage in the individual and group markets created difficulties as a result of the high price tag of HIV treatment.

Lastly, to qualify for Medicaid in most states, enrollees had to be both low income and categorically eligible—–such as pregnant or disabled––which excluded many low-income adults from coverage.

But several key provisions of the ACA removed these barriers, according to KFF. The ACA eliminated pre-existing condition exclusions; prohibited private insurers from denying coverage or charging higher premiums to individuals based on health status; eliminated annual and lifetime benefits; and provided subsides to assist with purchasing private coverage through the marketplaces for those between 100% and 400% of the federal poverty level (FPL).

States were also required to expand their Medicaid programs to cover eligible individuals below 138% of FPL, basing eligibility on income and residency status alone, KFF reported.

In June 2012, the US Supreme Court ruled that Medicaid expansion is a state option. To-date, 32 states and the District of Columbia have expanded their programs, according to the report.

As the fate of the ACA is unknown at this time, KFF sought to better understand how the ACA impacted coverage for individuals living with HIV.

The investigators analyzed data from the CDC’s Medical Monitoring Project (MMP), a surveillance system that produces national representative information regarding individuals living with HIV who are in care, according to KFF.

The KFF noted that data in their report are not representative of all individuals living with HIV in the United States, since the MMP only surveys individuals currently in care.

The investigators compared insurance coverage of HIV-positive patients in care in 2012—–before the implementation of major ACA expansion reforms––with care in 2014. The analysis examined nationwide changes, as well as changes within states that expanded Medicaid and those that did not.

Additionally, the investigators analyzed whether the role of the Ryan White Program changed over this period.

The results of the analysis showed that Medicaid coverage in HIV-positive individuals in care significantly increased nationwide, rising from 36% in 2012 to 42% in 2014. According to the report, the gains in coverage were driven by those in Medicaid expansion states, and a similar increase in coverage was not seen in non-expansion states. Overall, there were no significant changes observed in uninsured or privately covered individuals.

Changes were also observed in subgroups, such as income level, race/ethnicity, and gender. Those below 100% FLP saw a rise in Medicaid coverage rates from 53% in 2012 to 60% in 2014—–a group that also saw a decrease in uninsurance rates, according to the report.

Within Medicaid expansion states, the investigators found that Medicaid coverage significantly increased from 39% in 2012 to 51% in 2014, while the share of uninsured dropped from 13% to 7%, respectively. Significant differences were also found among subgroups.

Among non-expansion states, there were no significant gains observed in coverage or drops in the uninsured between 2012 and 2014. However, KFF said that individuals below 100% FPL saw gains in private insurance, increasing from 5% to 13%, respectively.

“It basically demonstrates that the Medicaid expansion made a significant difference in the lives of people with HIV in providing new and expanded coverage,” study author Jennifer Kates told Reuters. “The main takeaway is that for a population that faced a pretty significant barrier to Medicaid before the ACA, expansion of Medicaid made a big difference.”

Regarding the Ryan White Program, the role of the program increased since the implementation of major coverage reforms under the ACA. Nationwide, the proportion of HIV-positive patients in care who relied on program increased from 42% in 2012 to 48% in 2014. In particular, the share of individuals with private insurance who relied on the program rose from 23% to 28%, respectively, according to KFF.

Reliance on Ryan White among individuals with Medicaid also increased from 31% in 2012 to 38% in 2014, whereas, the uninsured experienced no significant change in reliance during the same period. Additional coverage changes were observed among some subgroups, according to the report.

Overall, individuals with HIV in the non-expansion states saw a significant increase in reliance on Ryan White (42% to 55%, respectively), and those with private insurance saw a dramatic increase from 17% to 38%, respectively.

“The ACA has played a significant role in increasing insurance coverage for people with HIV through Medicaid expansion,” the authors wrote. “Even though not all states have expanded Medicaid, coverage increases for people with HIV in expansion states drove a nationwide increase. At the same time, there was no significant decrease overall in the share who were uninsured, although this drop was significant in expansion states.”

The authors believe this is likely due to the 53% of individuals living with HIV in non-expansion states in 2014 with incomes below 100% FPL, who subsequently fell in the coverage gap.

Additionally, the share of individuals with Medicaid and private coverage who were reliant on the Ryan White Program increased. According to the authors, they believe that data reflects the program’s significant and growing role in providing aid to individuals with HIV, by providing services that their insurance may not cover, such as case management, transportation assistance, and longer, more complex provider visits.

“Overall, this analysis suggests that the ACA has had a significant impact on coverage for people with HIV in the US, due to Medicaid expansion,” the authors concluded. “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.”

It’s important to note, however, that in an interview with Vox, Benjamin Sommers, a health economist and physician at Harvard University, who found that Medicaid saves lives, said that the study has some limitations.

“HIV was the condition that was hardest to study well in that Medicaid expansion analysis, simply because New York—–the largest expansion state in that study––had an HIV prevalence that was far and away higher than any other state in the sample,” Sommers told Vox. “So it’s more challenging to say definitively that the HIV-related mortality reductions we found were just from insurance. My own take on the findings is that it was a combined effect of new effective therapies for HIV becoming widespread around the same time as this coverage expansion.”

A recent report by the CDC found that the number of annual HIV infections in the United States dropped 18% between 2008 and 2014, from an estimated 45,700 to 37,600.

CDC researchers believe the decline in annual infections are due, in large part, to efforts to increase the number of HIV-positive individuals who know their status and are virally suppressed, according to Reuters.

Although President Donald Trump has not specifically addressed HIV, he did rip into Martin Shkreli for increasing the cost of Daraprim by 5000%, according to MarketWatch.

“This young guy raised the price to a level that’s absolutely ridiculous, and he looks like a spoiled brat to me,” President Trump told reporters while campaigning, as reported by The Independent. “I thought it was a disgusting thing, what he did. I thought it was a disgrace.”

Daraprim is used to treat parasitic infections and prevent infections in the nervous system in patients with HIV. When Turing Pharmaceuticals obtained the rights of the drug, the retail price skyrocketed from $13.50 per pill to $750.