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An Update on Insurance Coverage Among People with HIV in the United States

In 2015, just 1 in 10 (11%) nonelderly people with HIV were uninsured, on par with the share in the general population that year (13%).1,2 In addition, while not directly comparable to the earlier MMP sample, this appears to have continued a downward trend that began in 2014, after ACA implementation. In 2014,14% of nonelderly people receiving HIV care were uninsured, down from 18% pre-ACA, in 2012.3

40% of people with #HIV are enrolled in Medicaid — the single largest source of insurance coverage for people with HIV in the U.S. States that expanded their Medicaid programs under the ACA have lower uninsured rates among people with HIV.

Medicaid remains the single most important source of coverage for nonelderly people with HIV, reaching 40% of in 2015,4 more than twice the rate of the general population (15%). While private insurance also plays an important role in coverage for people with HIV, rates are substantially lower than in the general population; just one third (34%) of people with HIV are privately insured compared to two thirds (68%) of the general population. As is the case with the general population (see Table 1), much larger shares of people with HIV get private coverage through an employer compared to the marketplace (25% v 6%).

Figure 1: Insurance Coverage Among People with HIV and the General Population, Nonelderly Adults, 2015

Table 1: Insurance Source Among Nonelderly Adults with HIV and Nonelderly Adults in the General Population, 2015
  People with HIV General Population
Uninsured 11% 13%
Medicaid 40% 15%
Medicare 7% 2%
Private – overall 34% 68%
Private – ESI 25% 59%
Private – Marketplace 6% 5%
Other 8% 2%
Notes: Data on people with HIV includes those 18-64 and general population data includes those 19-64; Those with Medicaid include those covered by Medicaid and another type of coverage, including those dually eligible for Medicare and Medicaid.
Source: For people with HIV: CDC MMP; All general population coverage data comes from KFF analysis of the 2015 American Community Survey (limited to nonelderly adults) except for Marketplace enrollment which is an estimate based on analysis of CMS effectuated enrollment, demographics of those selecting marketplace plans, and ACS data – see methods for more detail.

Medicaid Expansion

In our earlier analysis, we found that the main driver of coverage gains under the ACA among people in HIV care was Medicaid expansion.5 Similarly, in 2015, this continues to hold true. Among the states sampled, uninsurance rates were significantly lower in states that had expanded their Medicaid programs compared to non-expansion states (5% v 19%) and rates of Medicaid coverage were significantly higher (48% v 29%).

Figure 2: Figure 2: Insurance Coverage Among Nonelderly Adults with HIV in Medicaid Expansion and Non-expansion States, 2015

While overall rates of private coverage did not differ significantly between expansion and non-expansion states for this population, non-expansion states did see significantly higher rates of marketplace participation (8% v 5%), potentially from those individuals who would have been Medicaid eligible, if their states had expanded. Coverage rates of other insurance sources were similar between expansion and non-expansion states.

Table 2: Insurance Source Among Nonelderly People with HIV, by State Expansion Status
  Expansion States Non-Expansion States
Uninsured 5% 19%*
Medicaid 48% 29%*
Medicare 6% 8%
Private – overall 35% 33%
Private – ESI 26% 23%
Private – Marketplace 5% 8%*
Other 6%** 11%**
Source: CDC/Kaiser Family Foundation analysis of the MMP
* Coverage rates in expansion vs. non-expansion states, significantly different (p<.05).
**Due to small sample size, this finding should be interpreted with caution

Ryan White

The nation’s Ryan White HIV/AIDS Program provides outpatient HIV care, treatment, and support services to people with HIV who are underinsured and uninsured. The program also assists with purchasing insurance on behalf of clients with access to coverage. Overall, in 2015, about half (46%) of non-elderly people with HIV received assistance from Ryan White. Ryan White plays an especially important role for the uninsured, 82% of whom received assistance through the program (e.g. direct medical care, medications, insurance purchasing, and/or support services). Ryan White also plays a meaningful role for those with insurance coverage, supporting 41% in 2015 by addressing gaps in coverage and assisting with insurance and out-of-pocket drug and medical costs related to HIV care and treatment. A much higher percentage of those with marketplace coverage relied on Ryan White (60%) than those with employer sponsored insurance (31%), potentially reflecting the role of Ryan White in helping clients purchase insurance, especially among a group likely to have lower incomes relative to those with employer coverage.

Viral Suppression

Viral suppression (defined as having an undetectable viral load at the time of last available laboratory data) is a critical health indicator and a goal of successful HIV treatment. Viral suppression affords optimal health outcomes at the individual level and, because when an individual is virally suppressed they cannot transmit HIV, also has significant public health benefit.6 However, because viral suppression can change over time, especially depending on treatment adherence, it is also useful to look at sustained viral suppression (defined as having an undetectable viral load over all tests in the preceding 12 months), a stronger indicator of long-term successful antiretroviral treatment and its associated preventive benefits. We looked at both measures but focused our analysis on sustained viral suppression. As expected, overall rates of sustained viral suppression (62%) were lower than viral suppression at last test (70%).

While rates of viral suppression at last test did not vary by insurance coverage, rates of sustained viral suppression were significantly higher among those with private insurance and Medicare, compared to the uninsured.

Figure 3: Rates of Viral Suppression Among Nonelderly Adults with HIV, by Coverage, 2015

Table 3: Sustained Viral Suppression Among Nonelderly People with HIV, by Insurance
Overall 62%
Uninsured 54%
Medicaid 60%
Medicare 69%*
Private – overall 65%*
           Private – ESI 63%
           Private – Marketplace 66%
Other 63%
Source: CDC/Kaiser Family Foundation analysis of the MMP
* Rates of viral suppression significantly higher compared to the uninsured (p<.05).

Ryan White support appears to make a significant difference in sustained viral suppression. Overall, those with Ryan White support were significantly more likely to have sustained viral suppression than those without Ryan White (66% v. 58%). This trend was driven by those with both Medicaid and Ryan White, a group who saw higher rates of viral suppression than those with Medicaid but without Ryan White (65% v 57%). While the viral suppression estimates for the uninsured without Ryan White are unstable due to a small sample size, uninsured persons with Ryan White had much higher rates of sustained viral suppression compared with uninsured persons without Ryan White (62% v. 16%). Differences were not significant (or estimates were unstable) across the remaining insurance categories (i.e. Medicare, private insurance, and other types of insurance).

Table 4: Ryan White Coverage and Sustained Viral Suppression Among Nonelderly People with HIV, by Insurance
  Coverage & Ryan White Coverage & No Ryan White
Overall 66% 58%*
Uninsured 62% 16%**
Medicaid 65% 57%*
Medicare 74% 61%
Private – overall 69% 63%
           Private – ESI 65% 62%
           Private – Marketplace 69% 61%
Other 67%** 58%**
Source: CDC/Kaiser Family Foundation analysis of the MMP
* Rates of viral suppression significantly different between those with coverage and Ryan White and those with coverage and no Ryan White, (p<.05).
**Due to small sample size, this finding should be interpreted with caution

Discussion/Looking Ahead

The ACA has played a significant role in increasing insurance coverage for people with HIV, particularly through Medicaid in those states that expanded coverage. As of 2015, the uninsurance rate among nonelderly people with HIV was similar to that of the public at large. We also find that the Ryan White HIV/AIDS Program remains a critical source of care, treatment, and support for people with HIV, especially for those who are uninsured but also for a substantial share of those who do have coverage. Both insurance coverage and Ryan White were associated with higher rates of sustained viral suppression, a crucial indicator of optimizing the individual and public health benefits associated with antiretroviral treatment.

The future of the U.S. healthcare landscape continues to be a source of significant debate, with some parties seeking to repeal the ACA or certain aspects of the law and others aiming to move towards even more expansive coverage options. Either approach would stand to significantly impact coverage, and likely care outcomes, for people with HIV, as well as the success of the new Ending the HIV Epidemic Initiative. Looking ahead, it will be important to continue to monitor access to care and coverage among people with HIV, particularly given the importance of engagement in care and treatment in optimizing the individual and public health benefits of treatment.

Acknowledgments

The authors wish to thank Dr. Sharoda Dasgupta and Dr. Linda Beer of the CDC and Wen Zhou of ICF International, Inc., who were instrumental in this work in providing access to data, guidance, and conducting statistical analysis.

Key Facts Methods